Essential Questions for Clerking a Patient with Jaundice and Right Upper Quadrant Pain
When clerking a patient with jaundice and right upper quadrant pain, you should focus on a structured set of questions that help differentiate between biliary obstruction, hepatocellular disease, and other potential causes to optimize patient outcomes regarding morbidity and mortality.
History of Present Illness
Pain Characteristics
- Onset: When did the pain begin? Sudden or gradual?
- Duration: Constant or intermittent?
- Character: Sharp, dull, colicky, or burning?
- Radiation: Does the pain radiate to the back, shoulder, or elsewhere?
- Severity: On a scale of 1-10
- Aggravating/alleviating factors: Relationship to meals, position, or movement
Jaundice
- Onset: When did yellowing of skin/eyes first appear?
- Progression: Is it worsening, improving, or stable?
- Associated symptoms:
Associated Symptoms
- Fever (suggesting infection/cholangitis) 1
- Nausea or vomiting
- Weight loss (concerning for malignancy) 2
- Malaise and fatigue 2
- Pruritus (itching of skin) 2
Medical History
Liver Disease Risk Factors
- Alcohol consumption: Amount, frequency, duration
- Hepatitis risk factors: IV drug use, sexual history, blood transfusions, tattoos
- Previous liver disease: Hepatitis, cirrhosis, gallstones
- Previous biliary procedures: ERCP, cholecystectomy
Medication History
- Current medications (prescription and over-the-counter)
- Recent medication changes or new medications
- Herbal supplements or alternative medicines
- History of drug reactions affecting the liver 1, 3
Travel History
- Recent travel to areas endemic for infectious causes of jaundice
- Exposure to contaminated water or food 1
Systems Review
Gastrointestinal
- History of gallstones or biliary colic
- Previous episodes of similar pain
- History of pancreatitis 1
- Changes in bowel habits
Constitutional
- Fever pattern and duration
- Weight loss
- Night sweats
- Fatigue
Social History
- Alcohol consumption (detailed quantification)
- Recreational drug use
- Occupational exposures to hepatotoxins
- Diet history (recent changes, fatty food intake)
Family History
- Family history of liver disease
- Family history of gallstones
- Family history of hemolytic disorders
- Family history of malignancy (especially hepatobiliary)
Physical Examination Focus Points
- Vital signs (especially fever suggesting infection/cholangitis) 1
- Skin examination for:
- Jaundice distribution and intensity
- Spider angiomas (suggesting chronic liver disease)
- Palmar erythema
- Scratch marks (from pruritus)
- Abdominal examination:
- Right upper quadrant tenderness
- Murphy's sign (suggesting cholecystitis) 1
- Hepatomegaly
- Splenomegaly
- Ascites
- Neurological examination for signs of hepatic encephalopathy
Laboratory Investigations to Consider
- Liver function tests:
- Complete blood count (for signs of infection or hemolysis) 4
- Coagulation profile (PT/INR - may be prolonged in liver disease) 2
- Viral hepatitis serology 3
Imaging Considerations
- Ultrasound as first-line imaging for biliary tract visualization 1, 2
- Consider MRCP for further evaluation of biliary obstruction 1, 2
Potential Pitfalls to Avoid
- Failing to distinguish between obstructive and non-obstructive jaundice 5
- Overlooking biliary obstruction in elderly patients 2
- Attributing symptoms to other causes (e.g., pruritus mistaken for dermatological conditions) 2
- Delaying intervention in cases of cholangitis or complete obstruction 2
By systematically addressing these questions during clerking, you'll be able to efficiently narrow down the differential diagnosis and guide appropriate management to reduce morbidity and mortality in patients with jaundice and right upper quadrant pain.