54y/o female patient , k/c of HTN and DM , presented with Jaundice and abdominal pain for 3days.
What are important history points ?
What are you going to look for on examination?
What are DDx?
Onset , course , duration, previous similar hx
History of fever, itching
Associated symptoms of abdominal pain , N/V, change in stool or urine color
Previous history of hepatitis , liver disease , GB stones , hematological disease
History of alcohol , drugs
Mental status ( ? Hepatic Encephalopathy)
Stigmata of chronic liver disease
Signs of acute cholecystitis ( RUQ tenderness, Murphy sign
Jaundice classified to either ( pre-hepatic, hepatic, post-hepatic) or ( Unconjugated vs conjugated )
Patient had associates RUQ pain , that increase with fatty food , with no previous history of fever , hepatitis , CLD, no alcohol or drug history
Examination; vitally stable , -ve Murphy sign and no signs of CLD Labs ; had high bilirubin ( mainly conjugated) and ALP , with normal other LFT, normal CBC imaging : US showed CBD of 8mm with stones inside. GBS
What is the management ?
Would you do MRCP ?
First need to classify patient into ( high , intermediate , low risk )
High risk = ERCP
intermediate = MRCP / ERCP
Low risk = none
Classification is based on evidence , which are also classified into ( very strong , strong , and moderate )
High = 1 very strong / or 2 strong
Intermediate = [ ( all evidence ) – ( high ) ]
Low risk = 0 evidence
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