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Bedside approach to a case of


Focus on
Classifying jaundice as hemolytic , hepatocellular or obstructive Determine the etiology

Jaundice yellow tissue

Sclera yellow bilirubin > 3g/dl Urine is tea or cola coloured conjugated bilirubin Colour lemon yellow hemolytic jaundice orange yellow hepatocellular jaundice green yellow obstructive jaundice Stool

Yellow but no jaundice

Carotenoderma healthy with sclera spared Quinacrine 4- 37% of the cases Muddy sclera

Florescent light

Developing in matter of hours and deepening rapidly viral or drug induced hepatitis Long standing Mild hemolytic family history Deep obstructive Chronic liver disease alcoholics

Patient has fever

Malaria Leptospirosis occupational history Viral hepatitis Cholangitis Dengue hemorrhagic fever

Pain in abdomen
Sudden onset right upper quadrant colicy pain with chills choledocholithiasis and ascending cholangitis Epigastic and back ache pancreatic cancer Biliary obstruction but no pain with deterioration in health and decreasing weight malignant obstruction

Persistent obstructive jaundice Transient Viral hepatitis

Unilateral jaundice

Emphasize on
Drug history Predictable dose related - acetaminophen Unpredictable isoniazide

Clues to etiology
Travel / exposure to contaminant food Hep A / hepatotoxin Blood transfusion HCV, HIV, HBV High risk behaviour sharing needles , drug abuse , unsafe sex Alcohol Family history Hemolytic anemias, Wilsons disease

Associated features
Chronic liver cell failure distension of abdomen , anasarca , hemorrhoids, hemetemesis , Arthralgia , myalgia , rash viral hepatitis History of hepatobiliary surgery

Breathlessness heart failure Vit D and Vit A deficiency

General physical examination in a patient who has Icterus

Pulse Tachycardia fever , heart failure Bradycardia obstructive jaundice Tachypnea heart failure , fever Pallor hemolysis , malignancy , cirrhosis Pallor with knuckle pigmentation megaloblastic anemia Lymphadenopathy Virchows and Sister Mary Josephs nodes. Clubbing may be seen in chronic cholestasis.

Mental status hepatic encephalopathy hepatocellular jaundice Flapping tremors Fetor hepaticus Skin Brusing clotting factor defects Petechiae / purpura Thrombocytopenia of cirrhosis

Other integumentary manifestation of cirrhosis spider nevi, palmar erythema, leuconychia, alopecia Scratch marks, hyper pigmentation, xanthomas on eyelids, extensor surface and palmar creases - Chronic cholestasis Pigmentation of shin and ulcers sickle cell disease

Multiple venous thrombosis carcinoma of body of pancreas Ankle edema cirrhosis or IVC obstruction due to hepatic malignancy Stigmata of chronic liver disease spider nevi palmar erythema Raised JVP heart failure gynecomastia caput medusae KF ring Wilsons disease

dupuytren's contractures, parotid gland enlargement, testicular atrophy

Abdomen in jaundice
Caput medusae Ascitis cirrhosis / malignancy Palpation of Liver o non palpable - not always a good sign o Palpable Large nodular liver malignancy Smooth extra hepatic cholestasis Uniformly enlarged fatty liver Tender right heart failure, viral or alcoholic hepatitis , amyloidosis

Murphys sign cholecystitis Palpation of gall bladder Courvoisiers law Spleenomegaly hemolytic jaundice , portal hypertension

To summarise
Hemolytic jaundice Positive family history Acholuric urine Stool normal coloured Lemon yellow icteruc Anemia Hemolytic faces Spleenomegaly

Hepatocellular jaundice
Prodromal symptoms myalgia, fever, rash Urine and stool colour may not be normal Pruritus may be present Orange yellow icterus Bleeding manifestation may be present Tender hepatomegaly

Obstructive jaundice
Urine is dark Clay coloured greasy stools Pruritus Green yellow icterus Sinus bradycardia may be present Xanthelesma Murphys sign Vit A and D deficiency