Initial Approach and Consultation
Observation and Initial Thoughts
Recognize the setting as a counseling station based on the patient's purpose for visiting (blood test results).
Anticipate that the liver function test (LFT) is abnormal due to elevated unconjugated bilirubin levels.
Keep the data gathering concise and focused.
Critical Considerations
Prioritize ruling out hepatitis as the most severe cause of abnormal LFTs.
Address this during the consultation to avoid misdiagnosis.
Data Gathering
Initial Questions
Reason for the Blood Test: Start by asking why the test was conducted.
Constitutional Symptoms:
Fever
Nausea
Tummy pain
Pruritus (itching)
Jaundice
Weakness
Pale stools
Short Symptom Inquiry: Limit to 3-4 key symptoms if the patient reports generally feeling healthy.
PMAF TOSA Questions
Past Medical History
Medications: Crucial for understanding LFT derangement.
Family History: Important to note any similar conditions in family members.
Travel History: Relevant for Hepatitis A, especially related to recent outside food consumption.
Diet
Alcohol and Smoking: Ensure to signpost before asking these sensitive questions.
Sexual History: If time permits, although less critical.
Questions for Bloodborne Infections
Recent tattoos
Blood transfusions
Recreational drug use (IV)
Recent surgeries
Physical Examination
Necessary Examinations
General physical examination
Vital signs check
Abdominal examination: Check liver span and tenderness
Explaining Blood Test Results and Diagnosis
Blood Test Explanation
Simplify and explain the purpose of the tests:
Liver Injury Tests: AST, ALT (indicate no liver damage)
Liver Function Tests: Elevated unconjugated bilirubin indicating liver not functioning optimally
Suspect Gilbert Syndrome based on exclusion of other causes.
Introducing Gilbert Syndrome
Wait for the patient's reaction after mentioning the diagnosis.
Tailor further explanation based on their response.
Simplify the explanation:
Gilbert Syndrome is a genetic condition due to enzyme deficiency in the liver.
This enzyme is needed for detoxifying old blood cells.
Due to the deficiency, unconjugated bilirubin levels are elevated.
Reassure the patient about the condition's seriousness.
Further Investigations
Recommend a liver ultrasound (USG) to examine the liver.
Suggest a hepatitis screen to conclusively rule out hepatitis.
Patient Advice and Lifestyle Modifications
Advice for Liver Care
Avoid liver strain:
Prevent starvation and dehydration.
Manage stress effectively.
Consume alcohol in moderation.
Concluding the Consultation
Safety Netting
Advise on signs to watch for and seek medical attention if experiencing:
Weakness
Yellowing of skin or eyes
Any cirrhosis symptoms
Follow-Up
Schedule a follow-up appointment in two weeks to review test results and monitor progress.
Encourage the patient to ask any questions or express concerns during the follow-up.
Providing Information
Hand out relevant leaflets and pamphlets for further reading and understanding.
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