Jaundice case sheet for medicine
Jaundice Case Sheet
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| # | Section | Key Content |
|---|---|---|
| 1 | Patient Identification | Name, age, sex, ward, occupation, referral |
| 2 | Chief Complaint | Scleral icterus, dark urine, pale stools with duration |
| 3 | History of Present Illness | Onset/progression, characterisation (10 yes/no items), pain SOCRATES |
| 4 | Causative / Risk Factor History | Pre-hepatic (haemolytic), hepatocellular, obstructive, epidemiological |
| 5 | Past History | 12 structured yes/no fields |
| 6 | Drug & Allergy History | Medications, allergies, alcohol CAGE |
| 7 | Personal & Social History | Diet, smoking, IV drugs, sexual history, sanitation |
| 8 | Family History | Wilson's, haemoglobinopathy, hepatitis contacts |
| 9 | Review of Systems | GI, hepatic, constitutional, urine, stool, skin, neuro |
| 10 | General Examination | Vitals, icterus grading, full CLD stigmata checklist |
| 11 | Systemic Examination | Abdomen (Courvoisier's/Murphy's), CVS, RS, CNS with West Haven encephalopathy grading |
| 12 | Clinical Classification | Pre-hepatic / Hepatocellular / Obstructive comparison table + provisional DX |
| 13 | Investigations | 8 sub-sections: LFT table, haematology, serology (HAV/HBV/HCV/HEV/leptospira/malaria), tumour markers, imaging, special |
| 14 | Management Plan | Summary + disposition |
| 15 | Signature | Examiner + consultant sign-off |