Obstructive Jaundice and Differential Diagnoses

History Taking

• Initial Approach

  • Express empathy: "I'm really sorry to hear that, I'm here to help you out."

  • Use open-ended questions to encourage the patient to describe their symptoms.

• Chief Complaint: Tea-Colored Urine

  • Explore characteristics:

    • Color

    • Consistency

    • Odor

    • Volume

  • Ask about duration: "Since when do you have this?"

  • Determine the pattern: "Is it on and off? Is it constant or getting worse?"

• Epigastric Pain Exploration

  • SOCRATES: A mnemonic used to explore different the characteristics of pain.

    • Site: Where is the pain located?

    • Onset: When did the pain start?

    • Character: What is the pain like (e.g., sharp, dull, aching)?

    • Radiation: Does the pain spread anywhere else?

    • Associations: What other symptoms occur with the pain?

    • Timing: How long does the pain last? Does it come and go?

    • Exacerbating/Relieving factors: What makes the pain better or worse?

    • Severity: How intense is the pain?

• Pale Stools

  • If present, inquire about other liver-related symptoms.

• Risk Factors

  • Alcohol consumption: "Do you drink alcohol?"

  • Blood transfusions: "Have you ever had any blood transfusions?"

  • Dietary habits: "Do you eat street food?"

  • Injections: "Have you had any IV injections?"

  • Drug use: "Do you use any drugs?"

  • Travel history: "Have you traveled recently?"

  • Needle stick injuries: "Have you had any needle stick injuries?"

  • Occupation: "What is your occupation?"

  • Sexual history: "Are you sexually active? Do you practice unprotected sex? Do you practice safe sex?"

  • Family history: "Can I know about family history of cancers?"

  • Surgeries: "Have you had any surgeries?"

  • Fever: "Do you have any fever?"

  • Post-meal pain: "Do you have pain in your upper side after meals?"

  • Trauma: "Any trauma?"

  • High fats in blood: "Any high fats in your blood?"

  • Kidney, ureter, and bladder questions: "Ask about dysuria? Do you have any pain and burning on your passing urine? Any frequency? Fever?"

• Patient History Findings

  • Pain is in the center of the abdomen radiating to the back.

  • Dark urine is positive.

  • Pale stools are positive.

  • Jaundice is positive.

  • Weight loss: 6 kgs in one month.

  • Father had colon cancer.

  • Cholecystectomy is positive.

Physical Examination

• General Appearance: Note the patient's overall condition.

• Jaundice: Check for yellowing of the skin and eyes.

• Edema: Look for swelling, particularly pitting edema.

• Pallor: Assess for paleness, indicating anemia.

• Vitals: Measure temperature and blood pressure.

• Abdomen

  • Inspection: Observe for visible masses, swelling, or distention.

  • Palpation: Perform superficial and deep palpation to assess tenderness and organomegaly.

    • Assess for tenderness.

    • Check for hepatosplenomegaly.

    • Palpate the kidneys.

  • Percussion: Percuss for renal angle tenderness (kidney).

• Digital Rectal Examination (DRE)

  • Perform with patient consent and in the presence of a chaperone.

  • Assess for swelling, masses, and prostate size.

• Urine Dipstick Test: Check for bilirubin.

• Liver: Assess if the liver is enlarged and tender.

Diagnosis

• Most Likely Diagnosis: Obstructive jaundice.

• Explanation: The gallbladder produces secretions to digest food, and in obstructive jaundice, the tubes are blocked, preventing proper secretion.

• Concern: Possibility of cancer blocking the tubes.

  • Pancreatic cancer.

  • Cancer in the liver.

  • Spread of bowel cancer to the liver.

Differential Diagnoses

• Liver-Related

  • Cholangitis

  • Hepatitis (viral, alcohol, autoimmune)

  • Post-cholecystectomy syndrome

  • Strictures (narrowing in the ducts or tubes)

  • Stones in the tubes

• Pancreatitis

• Other Causes of Dark Urine and Abdominal Pain

  • Peptic ulcer disease.

  • Gastroesophageal reflux disease (GERD).

  • Pneumonia

  • Acute coronary syndrome

Cholangitis due to Cancer (Version 4)

• Findings

  • Temperature: $37.9$ (positive for fever)

  • Jaundice: Positive

  • Liver: Enlarged and tender

  • Urine dipstick: Positive for bilirubin

• Diagnosis: Cholangitis due to cancer