Jaundice - Bedside Evaluation

8/10/01 

RE: A 19 year old African-American male with nausea/vomiting, hematemesis, and black stool. 

Question: What are some difficulties in recognizing  jaundice in a patient, particularly in the presence of artificial lighting?

<1>

Unique Identifier: 20152932 / PubMed Identifier: 10691073

Authors: Hung OL. Kwon NS. Cole AE. Dacpano GR. Wu T. Chiang WK. Goldfrank LR.

Institution: Department of Emergency Medicine, Bellevue Hospital Center, New York University Medical Center, New York 10016, USA. olhung@pol.net

Abstract: OBJECTIVE: The evaluation of the patient through a comprehensive history and physical examination is considered the cornerstone of medical diagnosis, but many studies suggest that physicians have inadequate physical examination skills. It is unknown whether these skills are reliable and whether they can be adequately acquired through training. The objective of this study was to evaluate the ability of the clinician to detect the presence and discriminate the extent of clinical anemia, fever, and jaundice in an ED or hospitalized patient. METHODS: This was a prospective observational study of a convenience sample of patients presenting to the ED or admitted to the hospital who had a rectal temperature measurement within 30 minutes prior to the observation, serum hematocrit measurement on the day of observation, or serum bilirubin measurement one day prior to the day of observation. Observers' (emergency medicine attending physicians', resident physicians', and rotating medical students') estimated serum hematocrit, rectal temperature, and serum bilirubin values were obtained after each observation. Sensitivity, specificity, positive predictive value, negative predictive value, and mean absolute difference between actual and estimated values were calculated for each observer. RESULTS: The physicians detected the presence or absence of anemia, fever, and jaundice in patients with sensitivities and specificities of approximately 70%. Their predictions varied from the measured value on average by 6.0 +/- 4.6% for serum hematocrit, 1.3 + 1.1 degrees F for rectal temperature, and 3.4 +/- 5.3 mg/dL for serum bilirubin. Observer accuracy decreased when evaluating patients with high and low measured values. CONCLUSIONS: The ability to correctly perform and interpret the physical examination appears to be independent of the observer level of training, patient ethnicity, or patient gender. The examination for pallor, warmth, and jaundice is unreliable in predicting the corresponding laboratory or electronic measurement. Certain anemic, febrile, or jaundiced patients may not be reliably detected solely by a focused physical examination.

<2>

Unique Identifier: 92385847 / PubMed Identifier: 1515656

Authors: Pasanen PA. Pikkarainen P. Alhava E. Partanen K. Pirinen A. Janatuinen E.

Institution: Kirurgian klinikka, Kuopion Yliopistollinen sairaala, Finland.

Abstract: We studied the reliability of the clinical assessment and the discriminatory value of different symptoms and signs in diagnosing obstructive and non-obstructive diseases causing icterus and/or cholestasis. During a period of two-and-a-half years, clinical assessment done by both physicians-in-training and by senior physicians was completed for 266 patients, and the usefulness of different symptoms and signs was tested in 220 of these. Clinical assessment was found to be a reliable method in distinguishing between obstructive and non-obstructive conditions causing icterus, with the sensitivity of 92% and specificity of 86%. In cases of anicteric cholestasis, the sensitivity and specificity of clinical assessment were 74% and 80%, respectively. Abdominal pain and abdominal tenderness were significantly (p less than 0.01) associated with obstructive diseases, whereas an enlarged liver, fever and excessive consumption of alcohol were associated with non-obstructive diseases (p less than 0.01, p less than 0.05, p less than 0.05, respectively). Itching, vomiting, intolerance to fatty foods, previous cholecystectomy, abdominal tumour and clinical icterus had no discriminatory value. Clinical evaluation is a reliable method in the diagnostic workup of a patient with icterus or anicteric cholestasis, and it is still of crucial importance in directing further investigations.

<3>

Unique Identifier: 90041184 / PubMed Identifier: 2681857

Authors: Frank BB.

Institution: American Gastroenterology Association, Thorofare, NJ 08086.

Abstract: Many diagnostic studies and procedures are available for the evaluation of jaundice. By judicious selection of those that are most likely to lead to a prompt diagnosis and by weighing their relative risk and efficacy, the physician can better ensure the comfort and safety of the patient and the cost-effectiveness of medical care. A guideline is presented that recommends an approach to the evaluation of jaundice. It is based on a critical review of the literature and its application to clinical practice. [References: 42]

<4>

Unique Identifier: 89247905 / PubMed Identifier: 2655759

Authors: Elias E.

<5>

Unique Identifier: 67100255 / PubMed Identifier: 5227205

Authors: Ferguson WJ.