What comprehensive history should be taken for a patient presenting with new‑onset jaundice?

History Taking in the Patient with Jaundice

Obtain a structured history that immediately distinguishes between hemolytic, hepatocellular, and obstructive causes by focusing on medication exposure, alcohol use, infection symptoms, abdominal pain characteristics, and risk factors for biliary obstruction.

Essential Historical Components

Medication and Substance Exposure

• Document all medications, including antibiotics, NSAIDs, and herbal supplements (particularly galactagogues in post-partum patients), as drug-induced liver injury accounts for a significant proportion of jaundice cases 1, 2
• Inquire specifically about recent antibiotic courses, over-the-counter analgesics, and any herbal or alternative medicine products 1
• Establish the temporal relationship between medication initiation and symptom onset 2

Alcohol Consumption History

• Quantify alcohol intake in detail, as alcoholic liver disease is one of the most common causes of jaundice in the United States 2
• Document duration, frequency, and amount of alcohol consumption to assess for chronic liver disease 2

Infectious and Systemic Symptoms

• Assess for fever, rigors, and right upper quadrant pain (Charcot's triad), which indicates cholangitis requiring urgent biliary decompression 1
• In post-partum patients, evaluate for signs of sepsis, endometritis, or wound infection, as sepsis commonly causes jaundice with mixed laboratory patterns 1
• Document viral hepatitis risk factors including injection drug use, sexual exposure, travel history, and vaccination status 2, 3

Pain Characteristics

• Characterize right upper quadrant pain in detail: onset, duration, radiation to the shoulder or back, relationship to meals, and severity 4
• Recurrent episodic pain suggests biliary colic from choledocholithiasis, while constant severe pain may indicate cholangitis or malignancy 4

Hemolytic Indicators

• Ask about dark urine, pale stools, and symptoms of anemia (fatigue, dyspnea, chest pain, tachycardia) to identify hemolytic causes of unconjugated hyperbilirubinemia 1
• Document family history of hemolytic disorders or known hemoglobinopathies 5

Biliary Obstruction Risk Factors

• Inquire about prior biliary surgery, known gallstones, or previous episodes of cholecystitis 4
• A palpable gallbladder with jaundice (Courvoisier's sign) suggests malignancy in 87% of cases and requires expedited evaluation 4
• Document weight loss, anorexia, and pruritus, which suggest malignant biliary obstruction 2, 3

Chronic Liver Disease Indicators

• Assess for stigmata of chronic liver disease through history: prior episodes of jaundice, ascites, variceal bleeding, hepatic encephalopathy, or known cirrhosis 5, 6
• Document autoimmune disease history, as primary sclerosing cholangitis and primary biliary cirrhosis can present with jaundice 4

Critical Timing and Severity Assessment

• Establish the acuity of symptom onset, as acute presentations with hemodynamic instability, altered mental status, or signs of cholangitis require immediate intervention 1
• Document progression of symptoms: sudden onset suggests obstruction or hemolysis, while gradual onset suggests hepatocellular disease or malignancy 3, 7

Special Population Considerations

• In post-partum patients specifically, obtain detailed obstetric history including complications during delivery, blood loss, and any peripartum infections 1
• For all patients, document occupational exposures to hepatotoxins and recent travel to areas endemic for hepatitis 3, 8

Common Pitfalls to Avoid

• Do not overlook herbal supplements and over-the-counter medications, as patients often fail to report these unless specifically asked 1
• Do not assume all jaundice in alcoholic patients is from alcoholic liver disease—they remain at risk for other causes including choledocholithiasis and hepatitis 2
• Do not delay evaluation for cholangitis when the classic triad is present, as this requires urgent biliary decompression regardless of imaging availability 1