Abdome

n
Jaundice
Clinical Vignette
A 40-year-old patient has come to the outpatient clinic today because of jaundice.

Vital Signs
Temperature: 98.7 (37.0)
Blood Pressure: 130/70 mm
Hg Pulse: 98/min
Respirations: 18/min

Expected Tasks

The student’s teams should efficiently perform the following tasks during this lab:

Task Description

1 Practice Rehearse and demonstrate physical examination of the 40

abdominal system with your colleagues Minutes

2 Patient The Interviewing Student conducts a focused history for a 15

History patient presenting with jaundice. Time-out at the end of HPI Minutes
to discuss missing data up to that point.
3 Feedback The Interviewing student receives feedback on any 5
Debriefing remaining missing data from the encounter. Minutes
Discussion
4 Reasoning The Clinical reasoning facilitator will generate their 10
processed list and write their problem representation minutes
(Framing) based on the information from the patient history
5 Physical The Examining student performs the relevant physical 15
Examination examination for suspected differentials identifying the Minutes
discriminating clinical features.
6 Feedback The Interviewing and Examining students receive feedback 5
Debriefing on their communication skills. Minutes
Discussion
7 Patient Optional Home Assignment
Notes Both Teams should type a concise and reasonable patient
note using the provided template in 10 minutes. Then
compare their SOAP note with the provided sample.

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 Read the following before the lab

 Swartz’s Textbook of Physical Diagnosis “Chapter 14.”

 Lecture : Abdomen

Watch the following videos before the lab

 Lecture Notes: Abdomen

 Draping for Abdominal Examination https://www.youtube.com/watch?

v=G7AC027Ifeo&index=4&list=PLeSzYRV0yK6- 3hofNQnKvUrzK7F0RuuPZ

Comments on the videos:

o Focus on the draping techniques shown (not the physical examination)

 Abdominal Examination https://www.youtube.com/watch?

v=Ya_MGVBKuTQ&index=11&list=PLH8OvJClDBh1S0WFNY Nf6aXxwzl6yVkuB

Comments on the videos:

o Patient must be supine with arms at the side for the abdominal examination
o Palpation and percussion should remain separate examination skills
o Do not assess the femoral pulse in lab

 Surface anatomy of the Abdomen

https://www.youtube.com/watch?v=6lMKauO44rA

Answer These Preparedness questions before the Lab

1. Give examples for appropriate questions to identify the cardinal features of jaundice
(page 437)

Jaundice:
 “How long have you been jaundiced?”
 “Did the jaundice develop rapidly?”
 “Is the jaundice associated with abdominal pain? Loss of appetite? Nausea? Vomiting?
Distaste for cigarettes?”
 “Is the jaundice associated with chills? Fever? Itching? Weight loss?”
 “In the past year have you had any transfusions? Tattooing?”

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  “Do you use any recreational drugs?” If yes, “Do you use any drugs intravenously?”
 “Do you eat raw shellfish? Oysters?”
 “Have you traveled abroad in the past year?” If yes, “Where? Were you aware that you
may have consumed unclean water?”
 “Have you been jaundiced before?”
 “Has your urine changed color since you noticed that you were jaundiced?”
 “What is the color of your stools?”
 “Do you have any friends or relations who are also jaundiced?”
 “What type of work do you do? What other types of work have you done?”
 “What are your hobbies?”

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2. What are the different types of jaundice, how they can be differentiated according to history?

Mechanism Example Suggestive findings

Unconjugated
Increased bilirubin Common: Hemolysis Few or no clinical
production manifestations of hepatobiliary
Less common: Resorption disease; sometimes anemia,
of large hematomas, ecchymoses
ineffective erythropoiesis
Decreased hepatic Common: Heart failure —
bilirubin uptake
Less common: Drugs,
fasting, portosystemic
shunts
Decreased hepatic Common: Gilbert syndrome —
conjugation
Less common: Ethinyl
estradiol, Crigler-Najjar
syndrome, hyperthyroidism
Conjugated hyperbilirubinemia
Hepatocellular Common: Drugs, toxins, Dark urine
dysfunction viral hepatitis

Less common: Alcoholic

liver disease,
hemochromatosis, primary
biliary cirrhosis, primary
sclerosing cholangitis,
steatohepatitis, Wilson
disease

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http://www.msdmanuals.com/professional/hepatic-and-biliary-disorders/approach-to-the-patient-with-liver-disease/jaundice
 Intrahepatic Common: Alcoholic liver Gradual onset of jaundice
cholestasis disease, drugs, toxins, viral
hepatitis Pruritus

Less common: Infiltrative Dark urine

disorders (eg, amyloidosis,
lymphoma, sarcoidosis, Clay-colored stools
TB), pregnancy, primary
biliary cirrhosis, Steatorrhea
steatohepatitis
If long-standing, weight loss
Extrahepatic Common: Common bile Depending on cause,
cholestasis duct stone, pancreatic manifestations possibly similar
cancer to those of intrahepatic
cholestasis or a more acute
Less common: Acute disorder
cholangitis, pancreatic
pseudocyst, primary Dark urine
sclerosing cholangitis,
common duct strictures
caused by previous
surgery, other tumors
Other, less common Hereditary disorders
mechanisms (mainly Dubin-Johnson
syndrome and Rotor
syndrome)

3. Explain how past medical, family history, and social history can be significant to patient
presenting with jaundice, give example from the textbook or the lecture.

 Past medical history should identify known causative disorders, such as hepatobiliary
disease (eg, gallstones, hepatitis, cirrhosis); disorders that can cause hemolysis (eg,
hemoglobinopathy, G6PD deficiency); and disorders associated with liver or biliary disease,
including inflammatory bowel disease, infiltrative disorders (eg, amyloidosis, lymphoma,
sarcoidosis, TB), and HIV infection or AIDS.

 Family history: should include questions about recurrent, mild jaundice in family
members and diagnosed hereditary liver disorders. The patient’s history of recreational
drug and alcohol use should be corroborated by friends or family members when possible.

 Social History: should include questions about risk factors for hepatitis, amount and
duration of alcohol use, injection drug use, and sexual history.
4. What are the symptoms and signs of cirrhosis (page 465)

5. What are the signs and symptoms of hepatobiliary disease?

Features of Chronic Liver disease: ascites, asterixis, fetor hepaticus, muslce wasting,
Hepatobiliary gynecomastia, spider angiomas, palmar erythema, xanthelasmas or
diseases xanthomas, dupuytren’s contracture, parotid gland enlargement
Jaundice
Pruritus
Dark urine
Pale coloured stool
Steatorrhea
RUQ pain
Colicky pain

Task (1) Practice

Task (2) Patient Histroy

History of Presenting Illness
 Elicits further details of Jaundice:
Onset and Chronology:
o How was the jaundice discovered
o Onset: acute, relapsing-remitting, chronic
o Duration
 Constant
 Intermittent (Gilbert’s syndrome)
Position: Skin, Eyes
Transforming Factors:
o Exacerbating factors: stress, recent infection, foods (fava beans)
o Alleviating factors:
Quantification: Affect on daily life
Related symptoms: abdominal pain or distension, ankle sweeling, itching, vomitting, nausea,
loss of appetite, fever, malaise, weight loss, pale stool, dark urine, steatorrhea, signs of
bleeding (purpura, ecchymosis)
 Asks if patient is suffering from any other symptoms
 Ask about extra-intestinal manifestations for autoimmune disorders
 Asks about any recent illnesses
 Ask about recent travel
 Previous episodes of jaundice
 Elicits any gastrointestinal risk factors: IV drug user, family history of cirrhosis or hepatic
cancers, blood transfusions, tattoos, needle stick injuries

Past Medical History

 Ask about the relevant chronic medical illness, especially autoimmune conditions, hemolytic
anemis, heart failure, or Inflammatory bowel disease
 Ask about any vaccinations against Hepatitis B
Drug history
 Paracetamol, statins, antibiotics (rifampin), herbal medications
Allergies
Social history
 Alcohol (how much, how often, how long)
 Smoking, illicit drugs (injection drugs), recent travel (malaria), Occupation, Diet (water
consumption, smoky or fatty foods, consumption of shellfish, new restaurant) and lifestyle.
Sexual history
 Ask about sexual history
o Monogamous or multiple partners
o Type of intercourse (anal, oral, vaginal)
o Use of contraception
o Screening for STDs
OBGYN history
 For female, ask about an obstetric and gynaecological history (HELLP syndrome, intrahepatic
cholestasis)
Family History
 Ask about a family history of blood disorders (G6PD, Sickle cell, spherocytosis), inflammatory bowel
disease
Review of systems

Task (3) Feedback Debriefing Discussion

Task (4) Reasoning

Symptoms, Risk Factors or Exposure Processed List (in medical terminology )

(pertinent points) in patient words
1. Started 7 days ago Acute
2. Yellowing of my eyes Scleral icterus/Jaundice
3. I have not been eating well Loss of appetite
4. Scratching my arms Pruritus
5. Muscle aches Myalgia
6. Dark urine Conjugated
7. Pale stools

Describe your patient’s problem to your Tutor (Problem Framing)

“Acute onset of conjugated

hyperbilirubinemia” OR
“Acute onset of obstructive jaundice”

Task (5) Physical Examination

Clinical Vignette – Continued

A 40-year-old patient has come to the outpatient clinic today because of jaundice.

Given the differential diagnosis is one of these diseases

1. Choledocholithiasis
2. Cholecystitis
3. Hepatitis
1. Patient Preparation, Comfort & Dignity
2. Hand hygiene
3. Exam Organization
4. Examination of the Relevant System
Choledocholithiasis Cholecystitis Hepatitis
 Inspection
o From the foot of bed
 Symmetry
 Abnormal pulsations or
peristalsis
 Contour
o Right hand side of the
patient
 Surgical Scars
 Drain insertion
sites/fistulas
 Hernias (ask patient to
cough)
 Distended veins or
hemorrhages
 Auscultation
o Bowel Sounds
o Bruits
 Aortic
 Renal
 Iliac
 Percussion
o All four quadrants or nine
regions
o Organomegaly
 Liver Span
 Spleen (Left Anterior
Axillary Line)
 Palpation
o Superficial palpation RUQ tenderness RUQ tenderness RUQ tenderness
o Deep palpation
o Organomegaly
 Liver
 Spleen
 Kidneys
 Special Test Positive
o Assess of Cholecystitis Murphy’s sign
(Murphy’s sign)
o Assess for ascites
 Shifting dullness
 Fluid wave

5. Examination of additional System(s)

 Signs of Liver Failure
o Inspect the eyes
o Inspect the face
o Inspect the hand

Task (6) Feedback Debriefing Discussion

Teaching Points
 Approach to a patient with jaundice
 Identify possible risk factors for jaundice (drug use, STDs, etc)
 Able to differentiate the type of jaundice based on the history and physical examination
 Identify the signs of Liver failure
 Sample of Patient (SOAP) Note
Abdominal System

SUBJECTIVE
CC: “I am having pain in my belly”

HPI :Maria, Female Patient reports pain in the right upper quadrant for 7 days. It is constant,
crampy and is 4/10 in severity with no radiation. Aggravated with pressure and no known alleviating
factors. Patient notes loss of appetite and yellowing of the skin. The patient’s urine is darker and
stools are pale. This morning, it was noticed that the right arm was itchy. No sick contacts but admits
to recent illness with fever, body aches and flu like symptoms that eventually resolved on its own. No
diarrhea or vomiting. No weight loss or fever

PMH: No significant PMH, advised by physician to monitor diet one year prior. No previous surgeries.
Up to date on preventive health screenings and immunizations.

MEDs: daily multivitamin.

Allergies: penicillin.

FH: Family is obese. Father Hypertensive. Mother had surgery to remove gall stones.

SH: Chef. Non-smoker. Alcohol use up to 3 drinks on occasion no more than once a month. No
recreational drug use. Recent travel to Trinidad 2 weeks ago. Admits to consuming local foods and
drinks. No exposure to pets. No tattoos.

Sexual Hx: Monogamous sexual relationship with consistent condom use.

ROS: No headache, dizziness, chest pain, palpitations, sore throat, burning on urination, changes in
gait, joint pain, rashes.

OBJECTIVE
GA: Patient is a middle aged woman/man of medium build, currently in mild painful distress. Alert
and oriented to time, place and person.

V/S: T98.6 F, BP 110/80 mmHg, P 80/min, RR 14/min

HEENT: Atraumatic,Normocephalic. Mucus membranes pink and moist. No sclera icterus.

CVS: S1S2, No S3, S4 or murmurs

ABD: No surgical scars, abdominal distention, hernia or pulsations. Bowel sounds present. Aortic,
Renal and iliac bruits absent. Tympany in all nine regions. Tenderness in the RUQ. No guarding or
rigidity. No hepatosplenomegaly. Kidneys ballotable.

SKIN: Jaundiced noted on the palms bilaterally.

ASSESSMENT (DATA INTERPRETATION):

Diagnosis #1: Choledocholithiasis

HISTORY FINDING(S) PHYSICAL EXAM FINDING(S)
RUQ pain RUQ tenderness
Itchy skin Jaundice palms
Yellowing of the skin
Dark urine
Pale Stool

Diagnosis #2: Cholecystitis

HISTORY FINDING(S) PHYSICAL EXAM FINDING(S)
RUQ pain RUQ tenderness
Crampy pain Jaundice palms
Yellowing of the skin

Diagnosis #3: Hepatitis

HISTORY FINDING(S) PHYSICAL EXAM FINDING(S)
RUQ pain RUQ tenderness
Recent viral illness Jaundice palms
Yellowing of the skin

PLAN: (DIAGNOSTIC STUDY/STUDIES)

LFT, LDH
CBC
Ultrasound abdomen
Hepatitis Serology
Treatment :