Jaundice History

Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I have been asked to speak to you today because you have told us that you have noticed jaundice, or a yellow colour to your skin and eyes. I will ask you some questions to try to determine what might be causing the problem. Does that sound all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for seeking medical attention. For example, “Could you tell me about what has been going on?”

Try to let the patient speak for 30-60 seconds without interrupting them. This is referred to as the ‘golden minute’ and can provide valuable information about why the patient has sought medical attention, as well as cues about their ideas, concerns, and expectations (ICE), which you can explore later in the consultation.

History of Presenting Complaint

Next, you should gather more specific information about the patient’s presenting complaint to establish the differential diagnosis. You can use a mixture of open and closed questions. 

An example of an open question here would be: “When did you first notice your skin had changed colour like this?” or “Have you noticed any other symptoms alongside the jaundice you have told me about?” Examples of closed questions include: “Have you noticed any itching?” or “Has your poo become a paler colour?”

When taking a jaundice history, it may be useful to think about the following structure for your questions, as well as what useful information the patient’s answers give you about the likely diagnosis:

• Onset – when did the symptoms start, and what happened at the time of onset? E.g., “I’ve been having my usual gallstone pain for a few days, but then today I’ve had a fever and now my skin has turned yellow” suggests ascending cholangitis.
• Duration of symptoms – often, there will be other symptoms alongside jaundice. How long have they been feeling this way? E.g., “I’ve been feeling really achy and flu-like for a few days and thought I was coming down with something. Now this yellow colour has developed” makes you think about infective causes like viral hepatitis.
• Previous episodes – has this ever happened to them before? Episodic jaundice when the patient remains otherwise well suggests a diagnosis of Gilbert’s syndrome.
• Itching – the presence of itching (pruritus) can help to determine the cause of jaundice. Pre-hepatic jaundice (e.g., due to haemolysis or Gilbert’s syndrome) causes raised unconjugated bilirubin and is not associated with itching. Intra-hepatic, post-hepatic, or obstructive jaundice causes an increase in conjugated bilirubin, which is more likely to be associated with itching.
• Pain – jaundice is commonly associated with right upper quadrant (RUQ) pain, especially if the cause is related to gallstone disease. Painless jaundice is a red flag for serious pathology, including malignancy (e.g., pancreatic cancer) and should be investigated urgently.
• Stool changes – changes in the colour or consistency of stool can be a clue to the cause of jaundice. Any pathology causing cholestasis can cause pale, floating stools, as bilirubin does not reach the bowel, causing the stool to lack the usual brown pigmentation. Cholestasis can be caused by intra-hepatic pathology, (e.g., hepatitis, primary biliary cholangitis, primary sclerosing cholangitis) or post-hepatic pathology, (e.g., gallstones, cholangiocarcinoma, pancreatic cancer).
• Urine changes – similarly to the above, jaundice with cholestasis is associated with darker urine, as excess bilirubin is excreted via the kidneys rather than the bowel.
• Fever – causes of jaundice with fever include viral hepatitis and ascending cholangitis (Charcot’s triad – fever, RUQ pain, jaundice).

System-specific History

After establishing further history, you need to gather any relevant system-specific information; in this case, the relevant system is the gastrointestinal (GI) system. Try to think of GI symptoms that may present alongside jaundice and ask about these. 

It is important not only to ask about these symptoms, but also to consider why their presence or absence is important in narrowing down the differential diagnosis. 

GI system symptoms to ask about include but are not limited to:

• Nausea and vomiting – how frequently? What is being vomited up? E.g., stomach contents, bile, faeces, etc. Is the vomiting impeding the effectiveness of oral medication including analgesia?  Conditions such as pancreatitis can present acutely with vomiting and jaundice, whereas a longstanding history of vomiting, weight loss, and painless jaundice may make you more concerned for a pancreatic malignancy.
• Diet and appetite – has the patient lost their appetite? Asking about the patient’s diet may provide useful insight into the possible cause of their symptoms. e.g., an association between bouts of RUQ pain and fatty food prior to the development of jaundice may indicate a diagnosis of gallstone disease. 

Red Flags

It is important to ask about symptoms that may prompt you to consider more sinister causes of jaundice in the differential diagnosis, which may require more urgent investigation and management (e.g., malignancy).

You may need to use closed questions to rule out these symptoms. Patients may not always volunteer this information because they might find these symptoms concerning or may not have the same insight into their significance as you do. 

Red flags to screen for when taking a history of jaundice include:

• Weight loss – could indicate malignancy
• Abdominal mass – could indicate malignancy.

Relevant Systems Review

A systems review is a useful tool to ensure no important information from the history has been missed; however, it is key to think about which systems are relevant to review so that your questions remain pertinent to the presenting complaint.

Relevant systems to review when taking a history of jaundice include:

• Infectious Disease – could the patient have an infectious cause for their symptoms? The most likely cause with this history will be viral hepatitis. Are there any sick contacts, history of foreign travel, or consumption of contaminated food or water? (Hepatitis A or E). Are there any risk factors for contact with infected body fluids (e.g., needlestick injury, intra-venous drug use, needle sharing, recent tattoos)? Do you need to take a sexual history? (Hepatitis B and C).
• Haematology – does the patient have a haematological disorder that increases haemolysis (e.g., sickle cell disease)?

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic, you can gather information about how the patient feels about their symptoms, whether they have a specific worry or concern, and how they hope to move forward after seeking medical attention. Try to find your own style of asking about ICE that works for you; some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?” “What do you think might be causing these symptoms?”
• Concerns – “Is there anything that is worrying you about this jaundice?” ‘Have you read or Googled anything about your symptoms that has worried you?”
• Expectations – “Was there anything specifically you were hoping we’d do today?” “Do you have any ideas of what might happen next?”

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note when an existing condition may be of significance in the context of the presenting complaint of jaundice. If the patient is known to have gallstone disease or Gilbert’s syndrome, their past medical history may explain their presenting complaint. Alternatively a pre–existing condition may predispose them to developing new pathology that could cause jaundice, e.g., having ulcerative colitis can predispose patients to developing primary sclerosing cholangitis, or having one autoimmune condition (e.g., thyroid disease, coeliac, disease, rheumatoid arthritis) may predispose to developing autoimmune mediated conditions causing jaundice (e.g., primary biliary cholangitis or autoimmune hepatitis).

Don’t forget to ask about any prior similar episodes of this presenting complaint.

Ask about previous surgery the patient may have undergone, especially if it will help to rule in/out a differential diagnosis, e.g., if the patient has recently had their gallbladder removed in the past gallstone disease may be less likely, or if they have recently had an ERCP procedure, there is a risk of developing pancreatitis. 

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications that the patient may not think to volunteer, e.g., over the counter medications, herbal or alternative medication, contraception, HRT, injections such as B12 and medication given in acute settings (e.g., hospital, ED, out-of-hours doctors). Check whether the patient is compliant with their medication and taking it as prescribed.

Try to think about whether the information you are given could be relevant to the differential diagnosis, e.g., the patient presenting with jaundice who has just been started on antibiotics (e.g., co-amoxiclav or flucloxacillin). Always check that paracetamol has been taken appropriately and has not exceeded the maximum dose. Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn a bit more about the patient, beyond their presenting complaint.

• Who do they live with? Does anyone else at home or with the same travel history have the same symptoms, e.g., viral hepatitis? Do they have a social support network, in case of a potential debilitating or terminal diagnosis?
• Do they work? Do they need time off work to attend appointments and investigations? Do they need to inform their employer, e.g., communicable diseases in certain professions?
• Do they drive? Does their condition affect their ability to drive or attend appointments?
• Have they had contact with someone with similar symptoms, e.g., viral hepatitis?
• Have they recently returned from travelling abroad, e.g., viral hepatitis?
• Do they smoke?
• Do they drink alcohol? Taking a good alcohol history is key when taking a jaundice history. How much do they drink? Did they drink more in the past? How often do they drink? Can you calculate their units per day/week? If a high alcohol intake is suggested, you may wish to risk stratify their use with a questionnaire such as the AUDIT (alcohol use disorders identification test).
• Do they use recreational drugs? Recreational drug use, especially intravenous drug use or needle sharing, is a risk factor for hepatitis B or C.

Family History

Does anyone in the family have any GI-specific conditions? For example, a key risk factor for developing primary sclerosing cholangitis is a positive family history.

Do any health conditions run in the family, e.g., thyroid disease or other autoimmune conditions (increased risk of autoimmune causes of jaundice, e.g., primary biliary cholangitis, autoimmune hepatitis)?

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further through examination, bedside tests, or further investigation/imaging.

Last updated Jan 2025

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