Obstructive Jaundice History

Name

Age

Sex

Occupation

Residence

Marital status

Date of admission

C/o

Yellowish discoloration of eyes for 1 month

HPI:

Is this patient Has obstructive jaundice ?       The following

● Jaundice :     Onset , Progression ,intermittent or constant . How was noticed .degree of jaundice(deep yellow or light yellow).

● Dark urine onset amount

● Pale stool :constipation or diarrhoea . Colour(Pale-black-silvery).  Amount .Odor . Greasy in constancy . difficulty in flushing . The presence of Melaena.

● Itching: onset, site ,day or night , relieving and aggravating factors.

Symptoms of ascending cholangitis:

● Right hypochondrial pain:Onset, Duration , character, severity ,radiation , relieving and aggravating factors and  Association

● Fever onset .duration .day or night . High or low. Intermittent or constant .relieving factors

Symptoms of gastric outlet obstruction

● Vomiting :Onset , Number of times. Projectile .Relation to food .Containing old food. Odor.   effortless or associated with Ritching , Association  with anorexia or nausea.

● Easy satiety. Bloating and belching

Symptoms of systemic effect of obstructive jaundice:

● Change in behavior mood or sleep pattern.

● Bleeding  tendency :Bleeding gum  during teeth brushing , easy bruisability .Haemtemsis .epistaxis

Symptoms of malignancy:

Weight loss 

symptoms of anemia (Fatigability , SOB and palpitation on exertion ).

Symptoms of metastasis: 

● GIT :abdominal distension.

● CVS + Respiratory:cough with haemoptysis chest pain lower limb edema.

● CNS:loss of consciousness . Headache . Convulsion .

● Genitourinary:urine amount colour and frequency

● Menstrual cycle: menorrhagea

Fill the gap

●  e.g seen in x Centre received management .done endoscopy and biopsy

Past Medical History:

● Hospitalization

● Surgical operation

● Endoscopy or ERCP : when, how many time, was  diagnostic biopsy taken .if they did  stenting . Post procedure complications , followup and diagnosis .

● Blood transfusion

● History of anemia.

● History of jaundice or contact with patient with jaundice or hepatitis

● History of sickle cell anemia or hematological disease

Family History :

Family history of sickle cell disease

Family history of other malignancies

Drug History:

Long term medication

Chemo - radiotherapy.

Social History :

Home condition

Water and electricity

Level of education

Smoking

Alcohol abuser

Health insurance

Nutritional Habits