🟡 Clinical Pearl: Always be ready to suggest differentials and investigations. First-line tests 👉 LFTs, bilirubin, FBC. Imaging 👉 Abdominal ultrasound. In older patients with pronounced jaundice: – Painful jaundice → gallstone in CBD (choledocholithiasis). – Painless jaundice → cancer of head of pancreas (classic exam favourite). 🛠️ Management: ERCP for stone removal or stenting for obstruction.

👋 Introduction

🧼 Hand Hygiene: Wash your hands before beginning.
🙂 Patient Introduction: Introduce yourself, check name & DOB, explain the exam.
📝 Consent & Privacy: Gain consent, ensure good lighting & dignity with drapes.
📖 Context: Jaundice = yellow discoloration of skin/sclera from raised bilirubin due to liver, biliary, or haemolytic pathology.

🧰 Equipment Needed

Gloves
Good natural/artificial light (pen torch if needed)
Towel or drape for dignity
Stethoscope (if extending into abdominal exam)

📚 Background Information

Category	Cause	Mechanism	Key Features
Pre-hepatic	Haemolytic Anaemia	↑ RBC breakdown → unconjugated bilirubin	Anaemia, dark urine, splenomegaly, ↑ reticulocytes
Hepatic	Viral Hepatitis	Hepatocyte injury → impaired conjugation	RUQ pain, malaise, jaundice, ↑ ALT/AST
	Alcoholic Hepatitis	Alcohol-induced hepatocellular damage	Tender hepatomegaly, AST:ALT > 2, jaundice
	Drug-Induced	Medication hepatotoxicity	Jaundice + systemic features, temporal drug link
	Gilbert’s Syndrome	UGT deficiency → mild unconjugated rise	Intermittent jaundice triggered by stress/fasting
Post-hepatic	Choledocholithiasis	CBD obstruction by gallstone	Dark urine, pale stools, pruritus, biliary colic
	Pancreatic Ca (Head)	Tumour compressing CBD	Painless jaundice, weight loss, Courvoisier’s sign
	Cholangiocarcinoma	Bile duct malignancy	Progressive jaundice, itching, pale stools

🪜 Examination Steps

👀 General Inspection:
- Look for cachexia (malignancy/alcoholism), jaundice in face/skin, spider naevi, palmar erythema, dilated veins.
- Check hands for clubbing, nails for leukonychia (chronic liver disease).
👁️ Eye Examination: Inspect sclera for yellow discoloration (scleral icterus) – usually seen before skin changes.
👄 Mucous Membranes: Look under tongue & inner cheeks for yellowing – useful in darker skin tones.
🩺 Focused Abdomen:
- Palpate RUQ → hepatomegaly/tenderness.
- Percuss liver span, check for splenomegaly/ascites.
- Cancer → hard irregular liver, Ascites → advanced cirrhosis/obstruction.
📋 History Adjunct:
- Urine colour (dark) + stool colour (pale) = obstructive.
- RUQ pain/fever = cholangitis/stone.
- Painless jaundice + weight loss = pancreatic malignancy.

✅ Closure

Thank patient, allow to redress, maintain dignity.
Explain findings: “You appear jaundiced - we would need to do blood tests and imaging to find the cause.”
Wash hands, document findings clearly.

⭐ Key OSCE Points

Always examine in good light.
Look at sclera and mucous membranes first (early jaundice signs).
Systematic: General → Eyes → Skin → Mucosa → Abdomen.
Be ready to suggest investigations + management (LFTs, US, ERCP).

🚫 Common Pitfalls

Examining in poor light → missing subtle icterus.
Not checking mucous membranes (can miss early jaundice).
Rushing → skipping abdominal exam.
Not correlating with systemic signs of liver disease.

📚 References

Clinical Examination by Talley & O’Connor
Geeky Medics OSCE Resources
OSCEstop – Online practice stations

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OSCE Jaundice