Follow Up | Gilbert's Syndrome

Casebank Counselling
1

Where are you?
FY2 in GP surgery

Who the patient is:
Richard James, a 26-year old man who has come for follow up

Other information you have about the patient:
He had come for a well man clinic last week and he had blood tests done:

Blood tests results

Test Name Blood test
FBC Normal
U & E Normal
Creatinine Normal
FBS/PPBS Normal
AST/ALT/ALP/GGT Normal
Total Bilirubin 69 umol/L
Unconjugated Br 54 umol/L
Conjugated Br 15 umol/L

What you must do:
Talk to the patient, explain the results and discuss management

Patient Information:

  • Your name is Richard James,a 26 years old man
  • Last week you came to your GP practice for a well man follow up and you had blood test done. Today you are here for your results. You do not expect anything serious because you just came for check-up last week and you did not have any symptoms.
  • Your father had problems with his liver but the doctors said it was not a big problem. Your results were checked 3 times and they came back the same way.
  • If any doctor suggests rechecking the results tell him this is the 3rd time my blood tests have been rechecked.
  • You have got no symptoms.
  • You are married and you have got 2 children. You drink a bottle of wine over the weekend. You do not drink alcohol during the week.

Questions:

  • What is wrong with my results?
  • What will you do for me?
  • Is it something i should be worried about?

Examiners Prompt:

  • If candidate requests observations, say observations are normal.
  • If candidate requests to do a tummy exam, say abdominal exam is normal.

SETUP

  • 2 seats for patient and doctor, examiner siting and observing directly.
  • LFT RESULTS are available on the table in the cubicle.

Emotions and Attitude: Just calm and normal

Data Gathering

  • GRIPS,Shake hands and smile
  • I understand you have come to the GP a week ago, I also understand that you had some blood tests done; is there any reason why you came to the well man clinic?
  • Were there any other tests done?
  • Any presenting complaint?
  • Have you had any symptoms such as;
    • Fever, nausea, vomiting, pale stools, diarrhoea, jaundice, abdominal pain, dark urine, pruritus.
  • Systemic review
  • P3MAFTOSA
  • Travel & alcohol history
  • Genetic history( family history?)
  • Sexual history
  • Any weight loss? tired and lethargic?any lumps or bumps on your body?( RED FLAG)
  • Have you had gallstones in the past?any surgery to your liver or gall bladder?
  • Have you been diagnosed with any blood problems?
  • Are you taking any painkillers or any other treatment?
  • Have you had Tattoos?
  • Have you had any blood transfusions before?
  • Is there any chance you could have taken recreational drugs?
  • What kind of diet do you like?
  • What do you normally eat?
  • Do you eat out normally?

Pause

  • Explain the results to the patient (show him the results while explaining) and explain that
    We checked your results and a pigment called bilirubin which a part of the liver function test is high,tell you would like to examine his tummy, check his observations: Temperature, RR, BP, oxygenation).

EXAMINATION

  • Vitals/General Examination- mainly icterus/Abdominal Examination
  • Examiner will tell you- everything is normal.

Management

Diagnosis:

  • From what you’ve told me and after examining you, it is hard to say what could be the cause of the high levels of bilirubin, but I suspect one of the possible causes could be Gilbert’s syndrome.

PAUSE

Explain Diagnosis:

  • It is a condition where you have high levels of bilirubin in your blood and usually it is asymptomatic and you will have no problems, it runs in the family, and it doesn’t usually require treatment and any episodes of jaundice you could have will be short-lived.

MANAGEMENT

  • Routine investigations
    • We could arrange for a routine abdominal ultrasound scan and I would like to perform Hepatitis screen tests.
  • Treatment/Decision
    • Otherwise, no treatment is required.
  • It is highly recommended that you maintain a healthy balanced diet and avoid triggers such as stress, starvation, dehydration, and drinking excess alcohol.
  • Safety Netting
2 Likes
2

Great Work!! @joeben

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