Family medicine
Jaundice
Jaundice is the yellowish discoloration of the skin, sclera, and mucous membranes resulting from elevated serum bilirubin levels (hyperbilirubinemia) exceeding approximately 2–3 mg/dL.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Viral hepatitis (HBV acute flare / HAV / HEV) [9] | Acute onset, malaise, tea-coloured urine, ↑↑ALT > AST, +ve serology | 「最近有冇食過生蠔？有冇接觸過肝炎病人？」 |
| Alcoholic liver disease / MASLD [7] | Chronic heavy alcohol use or metabolic syndrome; AST > ALT (2:1 ratio in ALD) | 「你每日飲幾多酒？飲咗幾多年？」 | |
| Gallstone disease (choledocholithiasis) | Intermittent jaundice, RUQ colicky pain, ± fever [3] | 「肚痛係咪一陣一陣，右上腹嗰度？」 | |
| Serious Not To Miss | Malignant biliary obstruction (CA pancreas head, cholangiocarcinoma) [3][10] | Painless progressive jaundice + LOW/LOA + palpable GB (Courvoisier sign) | 「黃疸係咪越嚟越深？有冇瘦咗？肚有冇痛？」 |
| Acute liver failure | Encephalopathy + coagulopathy (INR > 1.5) + jaundice; no prior liver disease | 「有冇意識模糊？有冇流牙血或者瘀傷？」 | |
| Acute cholangitis | Charcot's triad: RUQ pain + fever + jaundice (surgical emergency) [4] | 「肚痛加發燒加黃疸，三樣一齊有冇？」 | |
| HCC on background CLD | Known HBV carrier + LOW + hepatomegaly | 「你知唔知自己有冇乙肝帶菌？」 | |
| Pitfalls | Drug-induced liver injury (DILI) | New drug/TCM in preceding weeks; ↑ALT | 「最近有冇食過新藥、中藥或者補品？」 |
| Gilbert syndrome | Mild unconjugated hyperbilirubinaemia during fasting/illness; normal LFT otherwise | 「係咪每次攰或者唔食嘢先至黃？」 | |
| Haemolytic anaemia | Lemon-yellow jaundice, normal-coloured urine (no bilirubinuria), dark stools, splenomegaly [2][11] | 「小便顏色正唔正常？有冇頭暈心跳？」 | |
| Masquerades | Drugs (paracetamol OD, statins, anti-TB) | Temporal relationship to drug | 「有冇食過大量止痛藥？」 |
| Decompensated cirrhosis (any cause) | Ascites, spider naevi, palmar erythema, gynaecomastia | 「肚有冇脹大？」 | |
| Trying to Tell Me Something? | Fear of liver cancer / fear of contagion to family / worry about alcohol dependency / work/financial stress | Hidden agenda: "my father died of liver cancer" | 「你最擔心係咩嘢？有冇嘢想同我講多啲？」 |
Exam framing for Jaundice in FM: The patient is most likely an adult presenting with new-onset jaundice in a primary care setting. Think viral hepatitis (HBV/HAV/HEV high prevalence in HK), alcoholic/MASLD liver disease, drug-induced hepatitis, gallstone disease, or malignancy. A neonatal/paediatric scenario is less likely in GC clinical test Station 1 but know the key discriminators.
Minute-by-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, ID, set agenda | 「你好，我係X醫生。請問點稱呼你？今日有咩嘢想睇吓？」(Hello, I'm Dr X. How should I address you? What brings you in today?) | Rapport, interpersonal skill marks |
| 0:30–1:30 | Chief complaint + HPI – onset, duration, progression; urine/stool colour; pain; itch; fever; weight loss; appetite | 「你幾時開始發覺眼白/皮膚黃咗？」「有冇覺得小便好似普洱茶咁深色？大便有冇變淺色？」「有冇肚痛？痕唔痕？」 | Core symptom analysis; differentiates pre-hepatic/hepatic/post-hepatic |
| 1:30–2:30 | Red flags & systems review – bleeding, confusion, vomiting blood, abdominal swelling, LOW/LOA, night sweats | 「有冇試過嘔血、屙血？肚有冇脹起？有冇瘦咗？」 | Identifies serious disorders – liver failure, malignancy |
| 2:30–3:30 | PMH, DHx, Allergy, FHx, SHx – hepatitis B/C carrier, gallstones, alcohol, drugs (paracetamol, TCM, herbal), IVDA, tattoo, travel, raw seafood, sexual history, occupation | 「你有冇乙型肝炎帶菌？飲唔飲酒？飲幾多？有冇食中藥或者補品？最近有冇去過旅行或者食過生蠔？」 | Drug/alcohol/viral history crucial; TCM is a common HK pitfall |
| 3:30–4:30 | ICE – Ideas, Concerns, Expectations | 「你自己覺得黃咗係咩原因？（Ideas）你最擔心啲咩？（Concerns）你今日嚟睇醫生最希望我幫到你啲乜？（Expectations）」 | Marks directly awarded for eliciting ICE |
| 4:30–5:15 | Uncover hidden agenda / RFC | 「除咗呢個問題之外，仲有冇其他嘢想同我講？」「點解揀今日嚟睇？係咪有啲嘢特別擔心？」 | "Why today?" reveals true RFC – e.g. fear of liver cancer, relative just diagnosed |
| 5:15–5:45 | Summarise & check understanding | 「等我總結吓：你大約X日前開始發覺皮膚黃咗，小便深色…我講得啱唔啱？」 | Shows active listening; interpersonal marks |
| 5:45–6:00 | Plan, safety-net, close | 「我建議今日幫你抽血驗吓肝功能同做個腹部超聲波。如果你有嘔血、意識模糊、肚好痛，就要即刻去急症室。」「你有冇嘢想問？」 | Safe closure; red-flag safety net |
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset/Duration | When did you first notice the yellow colour? | 「你幾時開始發覺自己黃咗？」 | Acute vs chronic aetiology | Acute → hepatitis, stone; chronic → CLD, malignancy |
| Urine colour | Has your urine become dark/tea-coloured? | 「小便有冇變深色，好似普洱茶咁？」 | Tea-coloured urine = conjugated hyperbilirubinaemia (cholestasis) [1][2] | Hepatic or post-hepatic cause |
| Stool colour | Have your stools become pale or clay-coloured? | 「大便有冇變淺色、好似白陶泥咁？」 | Pale stool = obstructive jaundice [2] | Gallstone CBD obstruction, malignant biliary obstruction |
| Pruritus | Do you feel itchy all over? | 「全身有冇好痕？有冇搲到損晒？」 | Pruritus ± scratch marks = post-hepatic (obstructive) jaundice [2] | Cholestasis – PBC, stone, tumour |
| Pain | Any abdominal pain? Where? | 「肚有冇痛？邊度痛？」 | RUQ pain → stone/cholecystitis; painless → malignant biliary obstruction (MBO) [3] | Painful = stone; painless progressive = malignancy |
| Fever/Rigors | Any fever or chills? | 「有冇發燒或者打冷震？」 | Charcot's triad (pain, fever, jaundice) = acute cholangitis [4] | Cholangitis – surgical emergency |
| Weight loss / LOA | Have you lost weight or appetite? | 「最近有冇瘦咗？食嘢點？」 | Constitutional Sx → malignancy | CA pancreas, cholangiocarcinoma, HCC |
| Bleeding | Any bleeding – gums, bruising, blood in stool/vomit? | 「有冇流牙血、瘀傷、嘔血或者屙黑便？」 | Coagulopathy → liver failure; ↑PT in jaundice = vit K malabsorption or liver failure [5] | Decompensated CLD, liver failure |
| Confusion/drowsiness | Any confusion or excessive sleepiness? | 「有冇覺得成日好攰、唔清醒、或者周圍嘅人話你反應慢咗？」 | Hepatic encephalopathy → liver failure [6] | Acute or acute-on-chronic liver failure |
| Alcohol | How much alcohol do you drink? Daily/weekly? | 「你飲唔飲酒？飲幾多？飲咗幾耐？」 | Alcoholic liver disease / alcoholic hepatitis [7] | ALD, MASLD if metabolic syndrome too |
| Drugs/TCM/Supplements | Taking any medications, Chinese medicine, or supplements? | 「有冇食緊藥？中藥？補品？止痛藥？」 | Drug-induced hepatitis – paracetamol, TCM, herbal very common in HK [2] | DILI |
| Hepatitis B/C | Are you a hepatitis B or C carrier? Any past hepatitis? | 「你有冇乙型肝炎帶菌？或者丙肝？之前有冇驗過？」 | HK prevalence of HBV ~7-8%; HBV is top cause of HCC [8] | Chronic HBV → cirrhosis → HCC |
| Raw seafood / Travel | Have you eaten raw shellfish/oysters recently? Any travel? | 「最近有冇食過生蠔或者生嘅海鮮？有冇去過旅行？」 | HAV/HEV from raw oysters [9] | Acute viral hepatitis A/E |
| Sexual / IVDA / Tattoo | Any new sexual partner, IV drug use, tattoo? | 「有冇新嘅性伴侶？有冇用過針筒？有冇紋身？」 | Parenteral/sexual transmission of HBV/HCV/HIV | Acute HBV, HCV |
| Family history | Any family member with liver disease or cancer? | 「屋企人有冇肝病或者肝癌？」 | Vertical HBV transmission; Wilson's, haemochromatosis | HBV-related CLD, Wilson's (young patient) |
| Occupation | What is your job? | 「你做咩工作㗎？」 | Occupational exposure; functional impact of illness | Healthcare worker (needlestick), construction (sick leave) |
| Functional impact | How does this affect your daily life/work? | 「呢個問題對你日常生活同工作有冇影響？」 | Biopsychosocial assessment | Social/functional problem for CRF |
Case Report Form Answer Builder
- CC: Jaundice (yellowish discolouration of skin/eyes) for [duration]
- HPI high-yield points to capture:
- Onset, duration, progressive vs intermittent
- Urine colour (tea-coloured → conjugated), stool colour (pale → obstructive)
- Associated: pruritus, pain (location, character), fever/rigors, weight loss, appetite
- Risk factors: alcohol, drugs/TCM, raw seafood, hepatitis B/C status, travel, sexual/IVDA history
- Red flags: confusion, bleeding, vomiting blood
- Examples: "Noticed yellow eyes for 1 week, worried about liver disease" / "Wife pointed out yellow skin, scared it might be cancer" / "GP found abnormal blood test"
- How to phrase: State the patient's own reason, not the medical diagnosis. E.g. "Patient noticed yellow skin and dark urine for 5 days, concerned about serious liver problem"
| Example Wording | |
|---|---|
| Ideas | "Patient thinks it may be related to alcohol / hepatitis B / the new Chinese medicine he started" |
| Concerns | "Worried about liver cancer because father died of it" / "Worried about infecting family" |
| Expectations | "Wants blood tests to check liver function" / "Wants referral to specialist" / "Wants to know if it is serious" |
- In an adult HK FM setting: Acute viral hepatitis (HAV/HBV flare) [9] or Gallstone-related obstructive jaundice – choose based on the stem:
- If raw seafood exposure + acute onset + ↑↑ALT → Acute hepatitis A/E
- If RUQ pain + fever + jaundice → Choledocholithiasis / cholangitis
- If painless progressive + weight loss → Malignant biliary obstruction
- If chronic alcohol → Alcoholic hepatitis/CLD
- Minimum supporting evidence: History features + one physical sign (see Q6)
| DDx | Key Discriminator |
|---|---|
| 1. Choledocholithiasis / cholangitis | RUQ colicky pain ± fever; intermittent jaundice; ↑↑ALP/GGT |
| 2. Drug-induced liver injury (DILI) | Temporal relation to new drug/TCM; ↑ALT |
| 3. Malignant biliary obstruction (CA pancreas / cholangioCA) | Painless progressive jaundice, weight loss, palpable GB (Courvoisier sign) [3][10] |
(Adjust list to the stem – always include at least one serious DDx)
| Domain | Problem |
|---|---|
| Biological | Underlying liver disease requiring investigation (LFT, viral serology, imaging) |
| Psychological |
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