After an open question, ask six things: pain, urine, stool, itch, fever and weight. Those six answers place almost every patient into pre-hepatic, hepatic or post-hepatic jaundice before any test is ordered. Then sweep the risk factors — drugs, alcohol, travel and contacts, previous biliary surgery — and finish with a summary that names a level and a leading cause.
Opening
Introduce yourself, confirm the patient's name and age, explain what you would like to do and gain consent. Then ask an open question and listen for at least thirty seconds before you start narrowing.
"I understand you've noticed some yellowing. Could you tell me about it from the beginning?"
The six questions
| Ask about | What to say | What the answer points to |
|---|---|---|
| 1 · Onset and course | "When did you, or someone else, first notice the yellow colour? Has it been getting steadily worse, or does it come and go?" | Sudden with pain — a stone. After a flu-like illness — hepatitis. Steady and relentless — malignancy. Comes and goes with fasting or illness — Gilbert syndrome. |
| 2 · Pain | "Have you had any pain in your tummy? Where is it, what is it like, and does anything bring it on, such as fatty meals?" | Right upper quadrant colic after meals — gallstones. Constant epigastric pain boring through to the back — pancreatitis or advanced pancreatic cancer. Painless and progressive with weight loss — suspect malignancy. |
| 3 · Urine and stool | "Has the colour of your urine changed? And your stools — are they darker or paler than usual? Are they greasy or hard to flush?" | Dark urine with pale stool — cholestasis or obstruction. Normal urine — haemolysis or Gilbert. Greasy stool — bile acids are not reaching the gut. |
| 4 · Itch | "Have you been itching anywhere? Is it worse at night?" | Cholestasis. In primary biliary cholangitis the itch often precedes visible jaundice by months. |
| 5 · Fever and rigors | "Have you had any fevers, or episodes of shivering and shaking you couldn't control?" | Rigors with pain and jaundice is Charcot's triad — cholangitis, an emergency. |
| 6 · Weight and appetite | "Has your appetite or weight changed? Do your clothes feel looser?" | Weight loss and anorexia suggest malignancy. New-onset diabetes in an older adult should make you think of the pancreas. |
The risk-factor sweep
- Past medical and surgical: gallstones, biliary colic, pancreatitis, previous cholecystectomy or ERCP, inflammatory bowel disease (which links to PSC), known liver disease, cancer.
- Drugs — all of them, including over-the-counter, herbal and traditional remedies, supplements and gym products, with the dates started and stopped. Co-amoxiclav, flucloxacillin, anti-tuberculous drugs, anabolic steroids, the oral contraceptive pill and paracetamol all matter.
- Alcohol: type, amount per day, units per week, pattern and last drink.
- Infection risk: travel, food and water, transfusion or surgery abroad, injecting drug use, tattoos, sexual history, household contacts with jaundice, occupation.
- Haemolysis clues: tiredness, breathlessness, a reaction to fava beans or certain drugs, a known blood disorder. G6PD deficiency is common in our region — ask specifically.
- Family history: jaundice, anaemia, splenectomy, gallstones at a young age, liver disease.
- Liver failure screen: confusion, drowsiness, reversed sleep pattern, easy bruising, bleeding gums, black stools, abdominal or leg swelling.
- In women: pregnancy and gestation, contraception.
Red flags — tell a senior now
- Rigors, hypotension or confusion — severe cholangitis
- Confusion or bleeding with new jaundice — acute liver failure
- Any paracetamol overdose, even "just a few extra"
- Jaundice in pregnancy
- Painless progressive jaundice with weight loss
- Melaena or haematemesis
A model summary
"Mr Khalil is a 68-year-old man with three weeks of painless, progressive jaundice associated with generalised itch, dark urine, pale stools and 6 kg of unintentional weight loss. He was diagnosed with diabetes two months ago. He has no fever, no history of gallstones, drinks no alcohol and takes no new medicines. My leading concern is a malignant obstruction of the distal bile duct, most likely a pancreatic head cancer; my differentials are an ampullary tumour or a common bile duct stone. I would like to examine him, looking in particular for a palpable gallbladder."
Notice what makes it work: it names a level and a leading cause, and it includes the pertinent negatives — no fever, no alcohol, no new drugs.
How to practise
Run the history against the clock — eight minutes, with a partner playing the patient — then present it in five sentences. The partner's only job is to score whether you asked all six questions. Most students lose marks on stool colour and on the drug history, not on the rare diagnoses.