Approach to a patient with Jaundice

Fahima Sultana & Amena Yasmin5th year studentM A G Osmani medical college, Sylhet

Discussion Topic

Evaluation of the patient presenting with jaundice, by

Proper History &Complete examination .

History taking

• Age of patient : children/young/old

• Evaluation of yellow discoloration:onset: sudden/gradualduration: short/lonngprogression: fluctuating/intermittent/progressivecolour of urine: normal/dark

Characteristic of stool : normal/pale, frothy, floats on water

Evaluation of associated symptoms

* Prodromal symptoms-like anorexia, nausea , vomiting, malaise

* High fever with chills and rigors* Abdominal pain or discomfort* Itching * Weight loss* Abdominal mass* Alteration of bowel habit

History for detection of aetiology

Accidental needle prick injuryPast history - jaundice with neurological problemPersonal history: IV drug abuse, tattooing sexual exposure Alcohol consumption Drug history: anti tubercular drugTreatment history: recent iv injection/ Infusion/blood transfusion/ surgeryFamily history : jaundice, malignancy,consanguinityTravel history, history of taking unhyegenic foodImmunization history

History regarding complications:

Mental confusion, disorientation , unconsciousness

Hematemesis , malena Respiratory distress Oliguria, puffiness of face Night blindness Bleeding manifestation Fracture of bone Growth retardation Bone pain, chest pain, hemoptysis

Clinical Examination

General Examination

Appearance : toxic/ thalassemic face/ disoriented Body built : below average/ chachexicCo-operation : co-operative or notDecubitus : on choice

Anemia : present/absent Jaundice : Mild/ moderate/ severe

Subicteric lemon yellow (acholuric jaundice) Various shades of yellow, Orange, dark olive green (obstructive jaundice) Have to exclude yellow of carotenaemia.

Cyanosis : absent/present Clubbing : present/absent Koilonychia : absent Leuconychia : absent/present

Edema : absent/present Dehydration : absent/ present Thyroid gland : not enlarged JVP : not raised Lymph node : palpable or not.

If palpable whether diffuse or single.

Pulse : with in normal range or raised Blood pressure : with in normal range Temperature : normal or raised Respiratory rate : with in normal range

Flapping tremor : absent/present Bony tenderness: absent/present Acholuric urine : Stigmata of CLD (hepatic facies,

parotid enlargement,spider angioma, xanthelasma)

Skin condition : scratch mark, tattoo, puncture mark, muddy complexion, peculiar greyish bronze colour

Systemic Examination

Examination of GIT

Inspection

abdomen – normal or distended umbilicus - centrally placed,

normal/everted transverse/vertical slitflanks - norlmal/full

Caput medusaAny visible mass

Palpation

local temperature – normal Taenderness – no/ present in the right

hypochondrium liver – palpable or not

tender/ non tender consistency hard/firm/soft surface smooth/irregular uni-nodular / multinodular bruit present/absent

Spleen – enlarged or not Gall bladder- palpable or not Testes – normal/ atrophied

• Percussion: shifting dullness – absent/presentfluid thrill – absent/present

• Auscultationbowel sound: present

Examination of nervous system• Glasgow Coma Scale : level of consciousness• motor weakness, Loss of peripheral sensation• Planter reflex : bilateral flexor/extensor

Examination of the respiratory system:signs of pleural effusion mass lesion

Examination of precordiumshifted apex beat

Take home message: Cluster clues

• An appropriate and complete history is always important for a diagnosis.

• A proper examination of the patient helps to find out the underlying cause