THEMEDPRACTICALEXAM.COM
Presenting Complaints
Yellowish discoloration of eyes and skin for ___ duration
History of Presenting Complaints
The patient noticed yellowish discoloration of the eyes and skin for the past ___ (duration). The discoloration started insidiously and has gradually progressed. Family members first noticed the change, and the patient subsequently observed it in the mirror.
Associated symptoms include:
Dark urine and pale (clay-colored) stools
Itching (pruritus), which may be generalized
Fatigue, malaise, and loss of appetite
Nausea or vomiting
Abdominal discomfort, especially in the right upper quadrant
Weight loss and early satiety (if present)
Abdominal distention (suggestive of ascites)
Swelling of legs (pedal edema)
Easy bruising or bleeding (gum bleeds, nosebleeds, black stools, vomiting blood)
Confusion, drowsiness, or altered sleep pattern (suggestive of hepatic encephalopathy)
Ask about the progression of jaundice: Was it sudden or gradual? Has it been persistent or intermittent?
Enquire about preceding symptoms such as fever, flu-like illness, or right upper abdominal pain (prodromal phase of viral hepatitis).
Ask about risk factors for CLD:
Alcohol intake: Type, quantity, duration, last intake
History of viral hepatitis: Past jaundice, blood transfusions, IV drug use, unprotected sex, tattooing, dialysis, healthcare work
Metabolic risk factors: Diabetes, obesity, hypertension, dyslipidemia (NAFLD)
Drug history: Use of hepatotoxic drugs (e.g., anti-tubercular drugs, methotrexate, amiodarone)
Autoimmune diseases: Personal or family history
Ask about previous similar episodes of jaundice, hospitalizations, or diagnosis of liver disease.
Past History
Any previous episodes of jaundice or hepatitis
Known diagnosis of chronic liver disease, cirrhosis, or related complications
Past blood transfusions, surgeries, or hospitalizations
Comorbidities: diabetes, hypertension, tuberculosis, heart or kidney disease
Family History
Family history of liver disease, jaundice, or inherited metabolic disorders
Any similar complaints in other family members
Personal History
Alcohol consumption: Type, amount, duration, last intake
Smoking or tobacco use
Diet: Appetite, recent weight changes, protein intake
Sleep: Any sleep disturbances or daytime drowsiness
Bowel and bladder habits: Any changes in stool color, consistency, or urine output
High-risk behaviors: IV drug use, unprotected sex, tattooing, travel to endemic areas
Socioeconomic History
Occupation, living conditions, and access to clean water and sanitation
Socioeconomic status (may affect risk of viral hepatitis, alcohol use, and access to healthcare)
Key points:
In CLD, jaundice is usually gradual and associated with other features of liver dysfunction (ascites, edema, pruritus, GI bleeding, encephalopathy).
Always inquire about risk factors for chronic liver disease and complications of decompensation
Anil Kumar/54/Male
Presenting Complaints
Yellowish discoloration of eyes and skin for 2 months
Abdominal distention for 1 month
Loss of appetite and weight loss for 1 month
History of Presenting Complaints
Mr. Anil Kumar, a 54-year-old male, noticed yellowish discoloration of his eyes and skin for the past 2 months. The discoloration began insidiously, first observed by his family, and has gradually progressed. He also reports dark-colored urine and pale stools for the same duration.
He complains of generalized itching, which is worse at night and has caused discomfort and scratch marks. He has experienced increasing fatigue, malaise, and a significant loss of appetite. Over the last month, he has noticed unintentional weight loss and early satiety.
About a month ago, he developed progressive abdominal distention, which has made it difficult for him to wear his usual clothes and lie flat comfortably. He has also noticed swelling of both feet, which is more pronounced in the evenings.
There is no history of fever, vomiting, abdominal pain, or acute episodes of severe discomfort. He denies any history of hematemesis, melena, gum bleeding, or easy bruising. There are no complaints of altered sensorium, sleep disturbances, or confusion.
He has not experienced any prior similar episodes of jaundice. There is no history of recent travel, blood transfusions, or contact with known cases of hepatitis.
Risk Factors and Relevant History:
He has been consuming country liquor (about 180 ml/day) daily for the past 20 years, with his last drink 3 days ago.
No history of intravenous drug use, unprotected sexual exposure, or tattooing.
No known history of diabetes, hypertension, or tuberculosis.
Not on any regular medications and no history of drug allergies.
Past History
No previous episodes of jaundice or hepatitis.
No prior diagnosis of chronic liver disease, cirrhosis, or related complications.
No history of previous hospitalizations, surgeries, or blood transfusions.
No history of diabetes, hypertension, or tuberculosis.
Family History
No family history of liver disease, jaundice, or inherited metabolic disorders.
No similar complaints in other family members.
Personal History
Alcohol: Regular intake of country liquor (180 ml/day) for 20 years.
Smoking: Smokes 4-5 bidis/day for 25 years.
Diet: Mixed diet, reports poor appetite and early satiety.
Sleep: Disturbed due to itching and abdominal discomfort.
Bowel and bladder habits: Noticed pale stools and dark urine; otherwise normal.
No high-risk sexual behavior or intravenous drug use.
Socioeconomic History
Occupation: Farmer.
Lives in a rural village with his wife and two children.
Lower-middle socioeconomic status.
Limited access to healthcare facilities and clean drinking water.
Summary:
Mr. Anil Kumar, a 54-year-old male with a significant history of chronic alcohol consumption, presents with gradually progressive jaundice, generalized pruritus, abdominal distention, pedal edema, loss of appetite, and weight loss over the past 2 months. There is no history of fever, GI bleeding, or altered sensorium. The clinical picture is suggestive of decompensated chronic liver disease, most likely secondary to alcoholic liver disease.
Biodata
Name: Mr. Ramesh Kumar
Age: 52 years
Gender: Male
Address: Village Rampur, District Jaunpur, Uttar Pradesh
Occupation: Farmer
Date of Admission: 20 May 2025
Presenting Complaints
Yellowish discoloration of eyes and skin for 2 months
Abdominal distention for 1 month
Loss of appetite and weight loss for 1 month
History of Presenting Complaints
Mr. Ramesh Kumar noticed yellowish discoloration of his eyes and skin about 2 months ago. The discoloration started gradually, was first noticed by his family, and has progressively increased. He also reports dark-colored urine and pale stools since the onset of jaundice.
About 1 month ago, he developed progressive abdominal distention, which has made his clothes tight and causes discomfort, especially when lying flat. He also complains of generalized itching, which is more severe at night.
He has experienced significant loss of appetite and unintentional weight loss over the past month. He feels full quickly after eating small amounts of food (early satiety). Swelling of both feet has developed in the last three weeks, more pronounced in the evenings.
He denies any history of fever, vomiting, abdominal pain, hematemesis, melena, gum bleeding, or easy bruising. There is no history of confusion, drowsiness, or altered sleep pattern. He has not had similar complaints in the past, and there is no history of recent travel, blood transfusions, or contact with known cases of hepatitis.
Past History
No previous episodes of jaundice or hepatitis.
No prior diagnosis of chronic liver disease, cirrhosis, or related complications.
No history of diabetes, hypertension, or tuberculosis.
No previous hospitalizations, surgeries, or blood transfusions.
Not on any regular medications and no known drug allergies.
Personal History
Alcohol: Consumes country liquor (about 180 ml/day) for the past 20 years, last intake 1 week ago.
Smoking: Smokes 5-6 bidis/day for 25 years.
Diet: Mixed diet, poor appetite in recent months.
Sleep: Disturbed due to itching and abdominal discomfort.
Bowel and bladder habits: Noticed pale stools and dark urine; otherwise normal.
No history of intravenous drug use, high-risk sexual behavior, or tattooing.
Family History
No family history of liver disease, jaundice, or inherited metabolic disorders.
No similar complaints in other family members.
Socioeconomic History
Occupation: Farmer.
Lives in a rural area with wife and two children.
Lower-middle socioeconomic status.
Limited access to healthcare facilities and clean drinking water.
Summary:
Mr. Ramesh Kumar, a 52-year-old male with a significant history of chronic alcohol consumption, presents with gradually progressive jaundice, abdominal distention, pruritus, loss of appetite, weight loss, and pedal edema over the past 2 months. There is no history of GI bleeding, fever, or altered sensorium. The clinical picture is suggestive of decompensated chronic liver disease, most likely secondary to alcoholic liver disease.
1. How are the causes of jaundice classified?
Answer:
Causes of jaundice are classified as:
Pre-hepatic (hemolytic): Due to increased breakdown of red blood cells (e.g., hemolytic anemia, malaria, hereditary spherocytosis)17.
Hepatic (hepatocellular): Due to intrinsic liver cell dysfunction (e.g., viral hepatitis, alcoholic hepatitis, cirrhosis, drug-induced liver injury)17.
Post-hepatic (obstructive): Due to obstruction of bile flow (e.g., gallstones, cholangiocarcinoma, pancreatic cancer, biliary atresia)17.
2. What are the hepatic (intrahepatic) causes of jaundice?
Answer:
Cirrhosis (chronic liver disease)
Viral hepatitis (A, B, C, D, E)
Alcoholic hepatitis
Drug-induced liver injury (e.g., isoniazid, rifampicin, methotrexate, amiodarone)
Autoimmune hepatitis
Malignancy (primary or metastatic liver tumors)
Genetic disorders (e.g., Gilbert’s syndrome, Crigler-Najjar syndrome, Dubin-Johnson syndrome, Rotor syndrome)17.
3. What are the typical clinical features of jaundice in chronic liver disease?
Answer:
Gradual onset of yellowish discoloration of eyes and skin
Dark urine and pale stools (if conjugated hyperbilirubinemia)
Generalized pruritus
Fatigue, malaise, loss of appetite, weight loss
Features of portal hypertension: abdominal distention (ascites), splenomegaly, pedal edema
Easy bruising or bleeding
In advanced cases: hepatic encephalopathy (confusion, drowsiness)56.
4. What tests are included in a routine liver screen for jaundice?
Answer:
Liver function tests (bilirubin, AST, ALT, ALP, GGT)
Synthetic function: PT/INR, serum albumin, platelet count
Viral hepatitis screen (HBsAg, anti-HCV, anti-HAV)
Autoimmune markers (ANA, ASMA, AMA)
Serum ceruloplasmin, ferritin, alpha-fetoprotein (AFP) if indicated1.
5. Which blood tests specifically assess the synthetic function of the liver?
Answer:
Prothrombin time (PT/INR)
Serum albumin
Platelet count1.
6. How does alcoholic liver disease typically present?
Answer:
Fatty liver: Usually asymptomatic, may have mild hepatomegaly
Alcoholic hepatitis: Jaundice, tender hepatomegaly, fever, features of liver dysfunction
Cirrhosis: Signs of chronic liver disease, portal hypertension, and decompensation (ascites, encephalopathy, variceal bleeding)689.
7. What is the pathogenesis of jaundice in chronic liver disease?
Answer:
Hepatocellular dysfunction impairs conjugation and excretion of bilirubin, leading to accumulation of both unconjugated and conjugated bilirubin in the blood (mixed hyperbilirubinemia)7.
In advanced cirrhosis, intrahepatic cholestasis and compression of bile canaliculi further impair bilirubin excretion7.
8. How can urine and stool color help differentiate types of jaundice?
Answer:
Dark urine and pale stools: Suggest conjugated (direct) hyperbilirubinemia, seen in hepatocellular and obstructive jaundice7.
Normal urine and normal-colored stools: Seen in unconjugated (indirect) hyperbilirubinemia (e.g., hemolytic jaundice)7.
9. What are the complications of chronic liver disease presenting with jaundice?
Answer:
Ascites
Spontaneous bacterial peritonitis
Hepatic encephalopathy
Variceal bleeding
Hepatorenal syndrome
10. How do you manage jaundice in chronic liver disease?
Answer:
Treat underlying cause (e.g., abstinence from alcohol, antiviral therapy for hepatitis)
Supportive care: nutrition, vitamin supplementation
Manage complications: diuretics for ascites, lactulose for encephalopathy, beta-blockers for varices
Liver transplantation in end-stage disease