- Wash hands and introduce yourself
Hepatitis (viral, alcoholic, autoimmune, drug induced)
Hepatic congestion (heart failure)
Cancer head of pancreas
Congenital hyperbilirubinemia (Gilbert’s syndrome)
- Check the patient’s name and DOB
- Ask if you can talk to the patient before they see the doctor
History of presenting complaint
- Ask what has brought the patient in today
- Ask them to tell you a bit more about the yellowing
- Where did you notice it first? Eyes, trunk, face?
- When did you first notice it?
- How has it progressed?
- Constant or come and go?
- Have you had it before?
- Is there anything that makes it worse?
- Ask about the following associated symptoms:
- Loss of appetite/weight loss (cancer, cirrhosis)
- Dark urine (biliary obstruction, haemolysis)
- Pale stools (biliary obstruction)
- Skin itching/pruritis
- Fever (hepatitis, cholangitis)
- Fatigue/malaise (cancer, cirrhosis)
- Rash (hepatitis)
- Confusion (hepatic encephalopathy, cirrhosis, cancer, fulminant hepatitis)
- Abdominal swelling/ascites (cirrhosis, congestion, cancer)
- Abdominal pain
- Biliary colic, radiation to right shoulder – gallbladder/cholangitis
- Recent bug/viral illness (exacerbates Gilbert’s syndrome)
- Alcoholism CAGE screen
- Do you ever think you should cut down on alcohol?
- Do you get annoyed when others comment on your alcohol intake?
- Do you every feel guilty about how much you drink?
- Do you ever have a drink in the morning?
- Heart failure screen
- SOB on exertion
- Short of breath in the night?
- Extra pillows at night
- Leg oedema
- Cough, frothy sputum
- Is there anything particular you are concerned about?
- Systems review
- Ask the patient if you can ask a few quick questions about their general health
- Headaches, faints, fits
- Changes in vision or sensation
- Chest pain
- Abdominal pain
- Change in bowel habits
- Change in waterworks
- Aches and pains
- Summarise and check what they have told you
Past medical history
- Ask if the patient has any current or past medical problems
- Ask if they have been jaundiced before
- Ask if they have had a blood transfusion before
- Ask if they take any medications, or if there have been any changes recently
- Ask about drugs that can cause hepatotoxicity
- Ask if they take any over the counter medications
- Ask if they take any supplements
- Ask if they have any allergies
- Ask what happens
- Ask if anyone in their family has had jaundice before
- Ask about liver and gallbladder problems in the family
- Ask about any serious medical problems in their close family
- Ask about smoking
- Ask about drinking, should have already covered
- Work out units
- What, when, with what, how often they drink
- Ask about recreational drugs, ask specifically about injecting drugs
- Ask about travel abroad (hepatitis)
- Ask about tattoos (hepatitis)
- Ask if there is any chance they could have picked up an STI in the last year (hepatitis)
- Ask if they have any questions or other concerns
- Ask if there is anything they think you missed
- Summarise again if appropriate
- Thank the patient for talking to you