History Taking : Jaundice

History Taking Scenario

Your Role

You are the medical SHO at the Gastroenterology clinic and are asked to see the following patient

Re : A,age 56 years

Dear Doctor,

Thank you for reviewing this gentleman who was found to have a raised ALT at a routine blood test.

His ALT has remained persistently elevated at 80 on repeat testing with otherwise normal liver function tests.

Mr A gives a history of previous alcohol excess but I understand that he is now abstinent.

Examination is unremarkable,

I have sent a screen for viral hepatitis which has been negative.

Please advise on further investigation and management.

Yours sincerely

Dr X

Important aspects


Main points on approaching the scenario.

Greet the examiner

Read the scenario in the time given for reading utilizing the time to carefully read the history and focus on main points.

What is being asked in the history.


Is there a clue in the history to the underlying diagnosis?

Memorize the name of the patient carefully

Now approach the patient

Greet the patient

Introduce yourself : I am Dr Gillani

I have been asked to ask you a few questions to better understand your problem.

Ask the patient what does he mean by jaundice ?

Has he or anybody else noticed a change in color of their eyes,ie they appear more yellow than usual ?
Sometimes patient will tell of associated symptoms only.

Give time to patient to let them explain about all their associated symptoms because jaundice is frequently a serious illness and should not be ignored.
Clinical Sciences Made Simple
History of Present Illness :

I believe you have been feeling unwell recently.

When was the last time you felt completely healthy.

How have you been feeling since then ?

Would you want to tell what has been going on ?

Ask about onset and duration of disease.

Since when did you notice that your eyes / skin have changed their color ?

How have things been progressing since then ?

Acute onset (Days )

Gall stone disease ( Cholangitis, Choledocholithisis)

Acute Hepatitis

Acute Budd Chiari Syndrome

Haemolysis

Subacute Onset ( Weeks – Months )

Pancreatic and hepatobiliary malignancy

Intrahepatic cholestasis ( eg drug induced, Auto immune , Infiltrative liver Disease )

Right sided Heart Failure

Recurrent Episodes :

Gallstone Disease ( cholangitis , choledocholithiasis)

Disorder of Bile transport eg ( gilbert”s Syndrome )

Associated Symptoms :

Fever :

Occurs in

Cholangitis

Viral hepatitis

Cholecystitis

Alcoholic hepatitis

Mirizzi”s Syndrome : Compression of hepatic duct by chronic inflammation in Hartman:s pouch of the gall bladder)

Right Upper quadrant Pain :

This occurs in cholangitis
.
Acute Hepatitis

Budd Chiari Syndrome

Mirizzis Syndrome

Gradual onset painless chelestatic Jaundice :

This occurs in

Pancreatic duct malignancy

Bile duct malignancy

Auto immune cholestasis

Drug related cholestasis

Confusion

Presence of confusion or altered mental status is strobly suggestive of a serious underlying proble such as :

Sepsis due to Cholangitis or

Hepatic encephalopathy due to Acute or Chronic Liver Failure

Other causes include

Intracranial haemorhage due to coagulopathy caused by Liver failure

Hypoglycemia due to Liver Failure

Or Post ictal state following seizure due to Alcohol or Substance Withdrawal

Mucosal Bleeding / bruising :

Ask specifically about gingival bleeding , nose bleeds and easy bruising.

Apart from coagulopathy caused by liver failure,other causes of mucosal bleeding and jaundice

include : DIC : Disseminated Intravascular coagulation due to cholangitis and sepsis,

Thrmobocytopenia due to portal hypertension ( Hypersplenism)

Thrombotic Thrombocytopenic purpura ( TTP) or

Severe Malaria

Back pain

can occur in Viral hepatitis along with Right Upper Quadrant pain and Severe Haemolysis.

Dark Urine and Pale stools

These are Classic symptoms of Obstructive Jaundice.

This occurs due to excess conjugated bile appearing in the urine.

Also lack of conjugated bile secreted into the intestines lead to a lack of stool pigment ( pale stools)

However severe haemolysis may cause dark urine due to haemoglobinuria.

Therefore,these questions may be better at following the progress of jaundice once the diagnosis is known rather than distinguishing obstructive jaundice from haemolysis.

Pruritis is a feature of all cholestatic processes including bile duct obstruction,drug induced and auto immune.

Other systemic diseases causing pruritis include :

Chronic Renal Disease

Haematological malignancy

Thyrotoxicosis

Weight Loss

Involuntary weight loss is associated with Pancreatic or Hepatobiliary Malignancy.

Patients with advanced Chronic Liver Disease are aso usually malnourished although their weight loss may be balanced by the development of ascites.

Associated Risk Factors :

Needle and Blood exposure :

Shared needles / iv drug abuse

Tattoos

Piercings

Dental or medical care abroad

Sexual History :

Ask sensitively about Sexual contacts ( Type of encounter : Heterosexual or Homosexual)
Number of partners

Use of barrier protection ?

Exposure to Hepatitis A

Drinking contaminated water ?

Exposure to individuals with viral illness

History of eating shell fish

Travel history in last 6 weeks ?

Recent Immunusuppression :

Patients who may be asymptomatic carriers of hepatitis B may develop liver failure due to viral reactivation after starting immunosuppressant therapy eg steroids and chemotherapy/.

Risk factors for Alcoholic Hepatitis and Acute Liver Failure

Alcohol Intake

Ask patient openly about Alcohol Intake

How much alcohol do you drink in an average weekend ?

Would you say you drink about one to two beers / whiskies a night or 8 – 10 beers / whiskies a night.
A lot of people feel alcohol helps them sleep at night . Do you feel the same ?

Now may be a good time to ask about CAGE Questionaire :

CAGE Questionnaire “CAGE” is an acronym formed from the italicized words in the questionnaire (cut-annoyed-guiltyeye).

The CAGE is a simple screening questionnaire to id potential problems with alcohol.

Two “yes” responses is considered positive for males; one “yes” is considered positive for females.

Please note: This test will only be scored correctly if you answer each one of the questions.

Please check the one response to each item that best describes how you have felt and behaved over your whole life.

Have you ever felt you should cut down on your drinking? __Yes __No

Have people annoyed you by criticizing your drinking? __Yes __No

Have you ever felt bad or guilty about your drinking? __Yes __No

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? __Yes __No


Offer help networks to try giving up alcohol.

Medications History :

Try to establish if the patient has been taking any hepatotoxic medications such as paracetamol.

Ask about any history of clotting disorder which can cause Budd Chiari Syndrome.

Any past history of Gall stones of hepato biliary surgery ? ( Risk of biliary strictures)

Travel History

Ask about any travel to South Eaast Asia , Eastern Eurpe or Sub Saharan Africa where there is a chance pt might havr acquired Hepatitis A or B

Family History

Try to elicit a family history of diseases below :

Hepatitis

Blood Disorders

Haemochromatosis

Wilson”s Disease

Gilbert”s Syndrome

Haemolytic Anemia

G6PD Deficiency.

Vaccination for Hepatitis A and B

Gyne & Obs History :

Ask about history of pre-eclampsia and low platelets in previous pregnancies ( to establish HELPP Syndrome )

Address any concerns the patient might be having

Discussion with Examiner

Formulating a plan of Action

Explain to the patient that a full clinical examination,blood tests and an ultrasound scan of liver

would be necessary to further determine the underlying diagnosis.

The Blood Tests which need to be done include :

Full Blood Count

Urea and Electrolytes including EGFR and Creatinine

Serum Paracetamol Levels

ABGs in unwell patients

Liver Function Tests ( Bilirubin, Alkaline Phosphatase and Alanine Transaminase )

Hepatitis A IgM , B s Ag and C Ab Serology

Serum Albumin and Total Proteins


Clotting profile including PT APTT and INR

Liver Smooth Muscle antibodies / Auto antibodies : that include : Anti smooth muscle Abs / Mitochondrial LKS antibodies)

Serum Iron , transferrin , TIBC and Ferritin tests for Haemochrmatosis

Serum Ceruloplasmin levels for Wilson”s Disease

Liver Biopsy if needed.