🔍 How to Approach Jaundice: Clinical Reasoning and Diagnostic Strategies for Visible Clues

When a patient says, “My eyes look yellow,” it may seem like a minor concern. But jaundice can indicate serious underlying conditions such as hepatitis, biliary obstruction, or malignancy.
This article guides medical students and junior residents through a step-by-step evaluation of jaundice—how to start, what to ask, and how to narrow down the differential diagnosis.
We’ll also cover essential OSCE topics such as bilirubin metabolism, the three main types of jaundice, and key physical exam findings. You’ll learn how to use tools like ultrasound and bilirubin fractionation in both clinical and exam settings.

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✅ What You Will Learn from This Article

• Three Major Types of Jaundice: Learn how to differentiate pre-hepatic, hepatic, and post-hepatic jaundice based on clinical signs like stool color, urine color, and pruritus.
• Diagnostic Strategies Using Bilirubin Tests and POCUS: Discover how to plan your investigations efficiently—even with limited information.
• Practical Communication and Clinical Tips: Explore how to take patient history, perform physical exams, and explain jaundice findings during OSCEs and real-life encounters.

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🧑‍⚕️ Case Introduction: “My Eyes Look Yellow” – A 60-Year-Old Man

🪪 Doorway Information
Age/Sex: 60-year-old male
Chief Complaint: Yellowing of the eyes and dark-colored urine
Vital Signs: T 36.8°C, HR 84/min, BP 136/78 mmHg, RR 14/min, SpO₂ 98% (room air)

“Doctor, my urine has been really dark lately. And… when I looked in the mirror, I thought my eyes looked a bit yellow.”
— He also mentions a slight loss of appetite over the past few days. His stools have become pale, and he reports some itching on his skin.

Faced with this case, how should we think through it? What clinical reasoning should guide our initial evaluation?
Let’s walk through the step-by-step approach to jaundice in the next section.

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🧠 How to Think When You See Jaundice: The Three Categories and Key Red Flags

Jaundice often presents as simple complaints like “my eyes look yellow” or “my urine is dark.” However, these symptoms may hide a wide range of serious conditions such as hepatitis, bile duct obstruction, hemolysis, or malignancy.

🔍 First, Is It Really Jaundice?

Before jumping to conclusions, the first step is to determine whether it’s true jaundice. For example:

• Carotenemia: Yellow skin but white sclera—common in high-carotene diets.
• Scleral icterus: Yellowing of the eyes due to elevated bilirubin levels—this indicates true jaundice.

🔬 The Three Categories of Jaundice

1. Pre-hepatic (Hemolytic): Excessive breakdown of red blood cells increases unconjugated bilirubin.
   ➤ Clues: Anemia, splenomegaly, no change in urine color.
2. Hepatic: Liver cell dysfunction due to viral hepatitis, alcohol, or drugs affects bilirubin processing.
   ➤ Clues: Elevated AST/ALT, mixed bilirubin elevation, liver enzyme pattern is key.
3. Post-hepatic (Obstructive): Blockage of bile outflow due to stones, tumors, or strictures leads to conjugated bilirubin buildup.
   ➤ Clues: Dark urine, pale (clay-colored) stool, pruritus.

In many cases, you can estimate the category of jaundice with just history and inspection—especially by asking about urine color, stool color, and itching.

⚠️ Commonly Missed Signs

• Intermittent jaundice: Seen in periampullary tumors that cause partial or fluctuating obstruction.
• Darker skin tones: Jaundice may be missed on skin—always inspect the sclera.
• Anchoring bias: Don’t assume jaundice = hepatitis. Consider bile duct disease or hemolysis.

In other words, jaundice is not just a color change—it’s a sign pointing to where bilirubin flow is impaired in the body.

In the next section, we’ll organize the diagnostic map using the structure of Fact / Problem / Hypothesis.

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🗺️ Step 0: Initial Mapping with Fact / Problem / Hypothesis

When you first encounter a patient with jaundice, it’s tempting to jump to diagnoses like hepatitis or gallstones.
But before anchoring, start by organizing your thinking into three layers: Fact, Problem, and Hypothesis.

🧩 Fact (What the Patient Tells You)

• “I think my eyes look yellow” (noticed by patient or family)
• Dark-colored urine
• Pale-colored stool
• Skin itching (pruritus)
• No fever, only mild fatigue

🔍 Problem (Medical Interpretation)

• Scleral icterus: Suggests elevated serum bilirubin
• Dark urine: Indicates elevated conjugated (direct) bilirubin
• Pale stool: Suggests reduced bile excretion into the intestines
• Pruritus: Points to cholestasis and bile salt retention

Interpretation: These features strongly suggest post-hepatic (obstructive) jaundice due to impaired bile outflow.

🧠 Hypothesis (Differential Diagnosis by VITAMIN CDE)

• Neoplastic: Pancreatic head cancer, cholangiocarcinoma, ampullary tumor (especially in elderly with weight loss)
• Infectious / Obstructive: Choledocholithiasis, cholangitis (Charcot triad suggests urgent condition)
• Iatrogenic: Post-surgical bile duct stricture, ERCP complication, drug-induced cholestasis (e.g., antibiotics, antipsychotics)
• Autoimmune: PBC, PSC (often under-recognized early due to isolated itching)
• Infectious (Hepatic): Viral hepatitis A–E, especially with recent travel or in younger patients
• Metabolic: Gilbert’s syndrome (intermittent, unconjugated)
• Congenital: Biliary atresia, Dubin-Johnson syndrome, Rotor syndrome

🔎 NTK – “Need To Know” Points for Clinical Thinking

• Urine and stool color, itching: Direct clues to bile flow disturbance
• Onset pattern (acute vs gradual): Suggests stones, tumors, or chronic disease
• Systemic signs (weight loss, fatigue, fever): Suggests malignancy or inflammation

Ultimately, jaundice tells us where bilirubin flow is disrupted. Even before formal history-taking, you can start forming hypotheses based on visible and reported signs.

In the next section, we’ll explore how to use OPQRST and PAM HITS FOSS to refine the diagnosis through history-taking.

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🩺 Step 1: History Taking – Classifying Jaundice with OPQRST + PAM HITS FOSS

Jaundice is one of those symptoms where the patient’s story can already point you toward the diagnosis—if you ask the right questions.
By using structured history-taking tools like OPQRST and PAM HITS FOSS, you can estimate the likely category (pre-, hepatic, post-hepatic) and narrow down the cause before labs or imaging.

🕒 OPQRST – Understanding Symptom Course and Quality

• O – Onset: When did the yellowing start? Sudden or gradual? Constant or intermittent?
• P – Provoking/Palliating: Any recent meals, medications, alcohol, or infections that triggered it?
• Q – Quality: Scleral icterus, dark urine, pale stool, itching—what changes did the patient notice?
• R – Radiation: Pain radiating to the back may point toward pancreatic or biliary pathology.
• S – Severity & Associated Symptoms:
  • How bothersome is the itching? Any impact on sleep or daily life?
  • Associated symptoms to ask:
    • Abdominal pain: Suggests biliary colic, hepatitis, pancreatitis (see here more in detailed: Abdominal pain)
    • Fever: Suggests cholangitis, hepatitis, liver abscess (see here more in detailed: Fever)
    • Weight loss or anorexia: Consider malignancy or chronic liver disease (see here more in detailed: wieght loss, anorexia)
    • Fatigue or confusion: May suggest hepatic encephalopathy (see here more in detailed: fatigue)
    • Dark urine / Pale stools / Itching: Classic triad for obstructive jaundice
    • Bleeding tendency: Gum bleeding, bruising (↓ clotting factors in liver failure)
• T – Timing: Has the color fluctuated throughout the day or over several days?

📚 PAM HITS FOSS – Uncovering Background Risk Factors

This expanded mnemonic helps you identify risks for infectious, autoimmune, metabolic, and iatrogenic causes of jaundice.

• P – Past Medical History: Prior episodes of jaundice, hepatitis, gallstones, hemolytic anemia, PBC, PSC, AIH
• A – Allergy: Any drug allergies, especially hepatotoxic agents
• M – Medications: Statins, antibiotics, antiepileptics, immunosuppressants, herbal supplements
• H – Hospitalizations: Past admissions, surgeries, blood transfusions
• I – Injury: Abdominal trauma (possible liver injury)
• T – Trauma (Procedures): Biliary surgeries, ERCP, cholecystectomy, liver biopsy
• S – Surgery: Hepatic or biliary operations
• F – Family History: Liver diseases, hemolytic conditions, PBC, AIH
• O – OBGYN (if applicable): Pregnancy history, intrahepatic cholestasis of pregnancy
• S – Social History: Alcohol use, smoking, occupational exposure, IV drug use
• S – Sexual History: Risk of HBV, HCV transmission, MSM (men who have sex with men)

🦠 Ask About Hepatitis-Specific Risk Factors

• Blood transfusions: Especially prior to 1990s—think HCV
• Recent health checkups: Any abnormal LFTs or liver masses previously noted?
• Travel history: Endemic regions for HAV/HEV (South/Southeast Asia, Africa)
• Food exposures: Raw oysters, undercooked meat, well water (HAV, HEV)
• Skin procedures: Tattoos, piercings, acupuncture—possible HBV/HCV risk

With just these historical details, you can often pinpoint the likely etiology of jaundice before ordering a single test.

Next, let’s see how to confirm your hypotheses through physical examination and POCUS.

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👀 Step 2: Physical Examination – Visual Clues and the Role of POCUS

Once you’ve narrowed the differential through history, the next step is to confirm or refute your hypotheses through physical examination.
In jaundice, visual inspection is essential, and POCUS (Point-of-Care Ultrasound) dramatically accelerates bedside diagnosis.

🧠 First Impressions – What You Should Immediately Observe

• Skin color: Is yellowing visible? Any asymmetry or patchy distribution (hands, soles, face)?
• Scleral icterus: The earliest and most reliable sign of jaundice
• Nutritional status: Wasting or sarcopenia may indicate chronic liver disease or malignancy
• Level of consciousness and speech: Consider hepatic encephalopathy or drug toxicity

Note: In patients with dark skin or pigmentation, scleral inspection is the most reliable method.

🔎 Head & Neck

• Eyes: Check for scleral icterus
• Oral mucosa: Signs of anemia, vitamin deficiency, fetor hepaticus (ammonia odor)
• Lymph nodes: Evaluate for lymphoma, liver cancer, or infectious causes

🫁 Chest and Heart

• Breath sounds: May suggest hepatic hydrothorax or hypoalbuminemic effusion
• Murmurs: Think of infective endocarditis or cardiac-induced liver congestion

🩺 Abdomen

• Liver size and edge: Irregular or hard → cirrhosis or liver tumor
• Murphy’s sign: Suggests cholecystitis or cholangitis
• Courvoisier’s sign: Painless palpable gallbladder → think pancreatic or biliary tumor
• Splenomegaly: Suggests hemolysis or portal hypertension
• Ascites: Look for shifting dullness or fluid wave

🦶 Skin, Extremities, and Peripheral Signs

• Palmar erythema: Often seen in chronic liver disease
• Spider angiomas: Typical of cirrhosis
• Nail findings:
  • Terry’s nails: Proximal 2/3 white—suggestive of cirrhosis
  • Clubbing: Seen in PBC, lung disease, or cancer
• Edema: May indicate hypoalbuminemia or liver-related fluid overload
• Excoriations: From pruritus—sign of cholestasis

🖥 POCUS – Essential Bedside Clues for Hepatobiliary Disease

Point-of-Care Ultrasound is one of the most powerful tools in evaluating jaundice—especially when patients present with classic findings like dark urine, pale stool, and scleral icterus.

• Gallbladder: Check for enlargement, gallstones, wall thickening, Murphy’s sign on probe compression
• Bile ducts: Dilated common bile duct (>6 mm), internal echoes (stones, tumors)
• Liver parenchyma: Fatty liver (bright echo), surface irregularity, masses, or cirrhosis signs
• Portal system & spleen: Portal vein dilation or splenomegaly → portal hypertension
• Ascites: Free fluid, possible fibrin strands if malignant or infected

Tip: In suspected obstructive jaundice, the combination of gallbladder enlargement + bile duct dilation suggests downstream blockage.
In contrast, signs like irregular liver edge, splenomegaly, and ascites raise concern for cirrhosis.

In summary, physical exam and POCUS are not just for confirmation—they’re tools to test your hypothesis in real-time.
Next, we’ll explore how to choose the right labs and imaging to reach a definitive diagnosis.

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🧪 Step 3: Labs and Imaging – Confirming the Diagnosis Strategically

Once your hypotheses are shaped by history and physical exam, the next step is to strategically select investigations that confirm or rule out key diagnoses.
In jaundice, the combination of bloodwork + urine analysis + imaging can efficiently localize and identify the underlying cause.

🩸 First-Line Blood Tests – Start with Bilirubin and Liver Enzymes

• Total Bilirubin (T-Bil): >2.0–2.5 mg/dL often produces visible jaundice
• Direct (Conjugated) / Indirect Bilirubin: Helps differentiate pre-, hepatic, and post-hepatic jaundice
• AST/ALT: Elevated in hepatocellular damage (ALT dominant in hepatitis)
• ALP / γ-GTP: Suggest cholestasis and bile duct obstruction
• LDH: Often elevated in hemolysis
• PT-INR: Indicates synthetic function of the liver (prolonged in liver failure)

Interpretation tip:
ALT↑ → Think hepatitis (hepatic jaundice)
ALP/γ-GTP↑ → Think bile duct obstruction (post-hepatic)

🦠 Viral & Autoimmune Serologies

• HAV IgM: Acute hepatitis A
• HBsAg, HBeAg, HBV DNA: Active hepatitis B
• HCV Ab, HCV RNA: Hepatitis C screening and confirmation
• HEV IgM: Consider in recent travelers to endemic regions
• ANA, AMA, SMA: Autoimmune hepatitis, PBC, PSC

🧬 HBV Panel Interpretation

HBsAg	Anti-HBs	Anti-HBc (IgG)	Interpretation
＋	−	＋	Current infection (acute or chronic)
−	＋	＋	Recovered infection with immunity
−	＋	−	Immunity due to vaccination
−	−	＋	Isolated anti-HBc (unclear status)

Note: Anti-HBc IgM (+) = acute infection. HBeAg (+) + HBV-DNA ↑ = high infectivity.

🚽 Urinalysis – An Easy Clue to Type of Jaundice

• Urine bilirubin: Only conjugated bilirubin appears in urine → hepatic or post-hepatic
• Urine urobilinogen:
  • ↑ → Suggests pre-hepatic (hemolysis)
  • ↓ or (−) → Suggests post-hepatic (blocked bile flow)
  • ± → Hepatic causes
• Other findings: Proteinuria, hematuria → check for comorbid renal or systemic illness

🖥 Imaging Strategy – From Ultrasound to MRCP

1. Bedside POCUS / Abdominal Ultrasound
   • Liver parenchyma: Echogenicity (fatty liver), nodular surface (cirrhosis), masses
   • Gallbladder: Enlargement, stones, wall thickening, gas (emphysematous)
   • Common bile duct: >6 mm = suspect obstruction (up to 7 mm in elderly)
   • Portal system & spleen: Portal vein dilation, splenomegaly → portal hypertension
   • Ascites: Free fluid or septations = malignancy or infection
2. Contrast-Enhanced CT
   • Detects pancreatic masses, cholangiocarcinoma, metastatic lesions
3. MRCP (Magnetic Resonance Cholangiopancreatography)
   • Non-invasive evaluation of bile duct strictures, ampullary lesions

📊 Non-Invasive Fibrosis & Fatty Liver Assessment

• Child-Pugh Score: Assesses severity of cirrhosis (encephalopathy, ascites, INR, albumin, bilirubin)
• MELD Score: Uses creatinine, bilirubin, and INR to evaluate liver failure
• FIB-4 Index: Based on age, AST, ALT, and platelets
• M2BPGi: Blood marker indicating liver fibrosis
• CAP, ATI, FibroScan: Tools for quantifying hepatic fat and stiffness

By combining these labs and imaging tools, you can determine where bilirubin flow is blocked—and why.
In the next section, we’ll apply these steps to our initial case and walk through how Step 1–3 guided the diagnosis.

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🔁 Case Reflection: Applying Step 1–3 to a Real Patient

Now that we’ve reviewed the framework of Step 1 to Step 3, let’s return to our case and apply each step to see how clinical reasoning unfolds in practice.

🗣️ Step 1: History Taking – Fact → Problem → Hypothesis

Doctor: “What brings you in today?”
Patient: “Over the last couple of days, my urine has gotten really dark. And someone told me my eyes look yellow…”

Doctor: “Have you noticed any change in your stool or any itching?”
Patient: “Yes, my stool has been pale and my skin feels itchy all over.”

Additional findings:

• OPQRST: Acute onset, persistent symptoms over 2–3 days
• PAM HITS FOSS: History of gallstones and alcohol use; no travel, transfusion, or drug history

Summary at this point:

• Fact: Scleral icterus, dark urine, pale stool, pruritus
• Problem: Suggests conjugated hyperbilirubinemia and cholestasis
• Hypothesis:
  • ★ Pancreatic head cancer or cholangiocarcinoma (elderly, progressive symptoms, pale stool)
  • ★ Choledocholithiasis or cholangitis (acute onset, RUQ pain)
  • ☆ PBC (though less likely in male, but itching is prominent)

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🧍‍♂️ Step 2: Physical Examination

Initial impression: Obvious scleral icterus, excoriation marks from itching, lean body habitus, alert and oriented.

• Eye: Strong scleral icterus
• Abdomen: Mild tenderness in right upper quadrant, no palpable mass, no ascites
• Skin: Excoriation present; no spider angiomas, Terry’s nails, or clubbing

POCUS findings:

• Common bile duct dilation (8 mm)
• No liver masses; liver surface relatively smooth
• No splenomegaly or ascites
• Gallbladder enlarged but no clear stone shadow seen

🧠 Clinical thinking at this point:
“The liver parenchyma doesn’t look damaged. Bile duct is clearly dilated, and stool is pale. This is pointing to a mechanical obstruction. I don’t see a stone… which makes me think tumor is more likely.”

Overall interpretation:
The combination of skin findings and POCUS strongly suggest biliary obstruction. The absence of visible stones increases suspicion for a malignancy causing the blockage.

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🧪 Step 3: Labs & Imaging

• Blood tests: T-Bil 6.2 mg/dL, Direct 4.8; mild AST/ALT elevation; marked ALP/γ-GTP elevation; PT-INR normal
• Urinalysis: Positive bilirubin, negative urobilinogen → supports obstructive jaundice
• Viral markers: HAV IgM, HBsAg, HCV Ab, HEV IgM – all negative
• Autoimmune markers: AMA, ANA negative

• CT findings: Mass in pancreatic head; dilated bile duct and enlarged gallbladder
• MRCP: Irregular narrowing from distal bile duct to ampulla region

🧠 Final clinical impression:
Biliary obstruction due to a pancreatic head tumor is strongly suspected. Liver enzymes show cholestatic pattern, and imaging confirms a suspicious mass.

Conclusion: At this stage, the most likely diagnosis is obstructive jaundice secondary to pancreatic head cancer. Referral to hepatobiliary specialists for biopsy and further management is indicated.

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📤 Step 11: When to Refer – Specialist Consultation and Pre-Referral Workup

Jaundice can arise from a wide range of etiologies—from benign to life-threatening. That’s why timing and clarity of referral are critical. Even without a confirmed diagnosis, knowing when to involve specialists prevents delays in treatment and optimizes care.

📌 Situations Requiring Specialist Referral

• Suspected malignancy: Pancreatic head mass, cholangiocarcinoma, ampullary tumor on imaging
• Biliary obstruction with systemic signs: Charcot triad (fever, jaundice, RUQ pain) → urgent referral
• Decompensated liver disease: Ascites, hepatic encephalopathy, elevated INR, hypoalbuminemia
• Autoimmune hepatitis, PBC, or PSC: Positive autoimmune markers or unexplained cholestasis
• Unexplained persistent jaundice: Despite initial workup, diagnosis remains unclear or disease is progressing

🧾 Minimum Pre-Referral Workup

Referrals are most effective when accompanied by key clinical information. Here’s what you should prepare before sending the patient to hepatology, gastroenterology, or hepatobiliary surgery.

• Blood tests:
  • Total & direct bilirubin, AST/ALT, ALP, γ-GTP, LDH
  • PT-INR, platelet count
• Viral serologies: HAV IgM, HBsAg, Anti-HBc IgG/IgM, HCV Ab
• Autoimmune markers: ANA, AMA, SMA (especially in women with cholestasis)
• Tumor markers (if appropriate): CA19-9, CEA, AFP
• Imaging: Abdominal ultrasound (POCUS), CT, MRCP – reports and image files if possible
• Urinalysis: Bilirubin, urobilinogen, protein, blood

📂 Additional Key Information

• Medical history: Previous liver/gallbladder disease, alcohol use, medications
• Exposure risks: Travel, blood transfusion, tattoos, sexual history, IV drug use
• Symptom timeline: OPQRST history + recent progression or changes

Referral tip: Clearly state your suspected diagnosis, working hypothesis, and what you have already ruled out.
This not only streamlines specialist assessment but also builds your credibility as a clinician.

Next, let’s review some practical clinical tips for approaching jaundice at the bedside.

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💡 Tips – Practical Skills for History and Physical Examination

Jaundice is a symptom you can literally see. That makes it all the more important to use simple, strategic techniques to catch clues early and avoid diagnostic delays.

🗣️ History Taking Tips

• Pay attention to how the patient starts the conversation: “My urine is dark” vs. “My eyes are yellow” can hint at where the process began.
• Always ask about stool color. Pale or clay-colored stool is a key sign of bile flow obstruction.
• Don’t underestimate itching—in some conditions like PBC, it precedes jaundice and may be the only early clue.
• Be thorough with questions about travel, supplements, IV drug use, tattoos, and MSM—these are high-yield for hepatitis risk.

👁️ Physical Exam Tips

• Check scleral icterus in natural light. Fluorescent lighting may obscure mild yellowing.
• Don’t stop at the face—inspect palms, trunk, oral mucosa, and scratch marks.
• Use percussion and auscultation to assess for hepatomegaly, splenomegaly, and ascites.
• Use POCUS liberally: it’s fast, noninvasive, and reveals critical clues like bile duct dilation or cirrhotic changes.
• When in doubt, look for “gallbladder enlargement + bile duct dilation”—it screams obstructive jaundice.

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✨ Clinical Pearls

“The eyes may see yellow before the labs do.”
— Clinical adage in hepatology

Never underestimate the power of visual inspection. Scleral icterus often precedes laboratory-confirmed hyperbilirubinemia and may be the earliest clue in biliary disease or liver dysfunction.

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🗣️ OET Speaking Session – Jaundice Evaluation in Primary Care

👥 Scenario

You are a general practitioner. A 60-year-old man visits your clinic complaining of yellowish eyes and dark-colored urine. He has no fever but reports mild fatigue, pale stools, and some skin itching.

You suspect obstructive jaundice and want to assess for possible biliary obstruction or malignancy.

🎯 Your Task

• Explain what jaundice is and what may cause it
• Gather key history: onset, color changes, associated symptoms
• Reassure the patient and address concerns about liver disease or cancer
• Explain the need for blood tests and imaging
• Discuss referral to a specialist if needed

💬 Sample Statements

• “Jaundice means there’s too much of a yellow substance called bilirubin in your body, which can cause yellowing of the eyes or skin.”
• “Sometimes it’s due to liver inflammation, but in other cases, it may be caused by a blockage in the bile duct.”
• “We’ll do some blood tests and an ultrasound to find out what’s going on. If needed, we may refer you to a liver specialist.”

💬 Common Patient Cues & Sample Doctor Responses

🧠 Challenging Questions & Sample Doctor Responses

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✉️ OET Writing Task – Sample Referral Letter

Today’s Date

Dr. Emily Tan
Hepatobiliary Surgery Department
Green Valley Medical Center

Re: Mr. Hiroshi Saito, 60 years old

Dear Dr. Tan,

I am referring Mr. Hiroshi Saito, a 60-year-old man, for further evaluation of suspected obstructive jaundice, possibly related to a pancreaticobiliary lesion.

Mr. Saito presented with a 3-day history of dark urine, pale stools, and progressive yellowing of the sclera. He also reports generalized pruritus and mild fatigue. There is no fever or abdominal pain, and no significant past medical history apart from treated hypertension.

On examination, scleral icterus was evident without abdominal tenderness or palpable masses. Bedside ultrasound revealed a dilated common bile duct (8 mm) and gallbladder enlargement. No gallstones were visualized.

Initial labs showed elevated conjugated bilirubin (T-Bil 6.2, Direct 4.8), markedly elevated ALP and γ-GTP, and only mildly elevated transaminases. Viral and autoimmune markers were negative. CT imaging revealed a mass near the pancreatic head with associated biliary dilatation.

We would appreciate your assessment for tissue diagnosis and surgical planning. Please feel free to contact us if further information is required.

Yours sincerely,

Dr. [Your Name]
General Practitioner

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🧾 Summary – What Jaundice Can Reveal Beneath the Surface

Jaundice is one of the most visible signs in medicine. But beneath that yellow hue lies a vast differential—from reversible inflammation to malignant obstruction.
This article outlined a structured, step-by-step approach using clinical reasoning to navigate cases of jaundice, especially in primary care and OSCE settings.

• History: Stool/urine color, pruritus, fatigue, and risk exposures are high-yield clues
• Physical exam: Don’t just “look”—observe with intention. Scleral icterus may appear before lab changes
• Labs & Imaging: Use bilirubin fractionation, transaminase patterns, and ultrasound to pinpoint location and cause

Most importantly, don’t stop at identifying jaundice—investigate the underlying disease process that’s disrupting bilirubin metabolism or excretion.

🧠 Differential Diagnosis by VITAMIN CDE

• V – Vascular: Hepatic infarction, Budd-Chiari syndrome
• I – Infectious: Hepatitis A–E, cholangitis, liver abscess, malaria
• T – Trauma: Post-surgical bile duct injury, ERCP complications
• A – Autoimmune: AIH, PBC, PSC
• M – Metabolic: Gilbert syndrome, hemochromatosis, Wilson’s disease
• I – Iatrogenic/Drugs: Antibiotics (e.g., amoxicillin-clavulanate), statins, antiepileptics
• N – Neoplastic: Pancreatic head cancer, cholangiocarcinoma, HCC, ampullary tumor
• C – Congenital: Biliary atresia, Dubin-Johnson syndrome, Rotor syndrome
• D – Degenerative: NAFLD/NASH with advanced fibrosis, cirrhosis
• E – Endocrine/Environmental: Pregnancy-related cholestasis, sepsis-related liver dysfunction

If this article helps you pause, observe, and think twice the next time you see yellow eyes—then mission accomplished.

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🔗 Related Articles

• How to Approach Fever – Differentiating Infection with Physical Clues
• Abdominal Pain – From History to Emergency Red Flags
• Unintentional Weight Loss – Exploring Malignancy, Endocrine, and GI Causes
• Abdiminal mass & distention – How to approach and assess
• Hematemesis – Complication of LCs & its approach or managenent
• 【日本語版】黄疸の診かた｜ビリルビン代謝から見える病態と鑑別

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📚 References

1. UpToDate. Approach to the adult with jaundice or asymptomatic hyperbilirubinemia. Retrieved July 2025 from: https://www.uptodate.com
2. American College of Gastroenterology. Guidelines for the Evaluation of Liver Chemistry Tests. Am J Gastroenterol. 2017;112(1):18–35.
3. Goldman L, Schafer AI. Goldman-Cecil Medicine, 26th Edition. Chapter 147: Approach to the Patient with Liver Disease. Elsevier, 2020.
4. Oh’s Intensive Care Manual. 8th Edition. Chapter: Hepatic Failure and Bilirubin Metabolism. Elsevier, 2022.
5. The Japan Society of Hepatology. Guidelines for the Management of Liver Diseases 2023. Tokyo: Nankodo.

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