This issue includes 4 hours of ACEP/AMA category 1 CME credit.

Authors: Matthew Wheatley, MD, and Katherine L. Heilpern, MD
Peer Reviewers: James F. Fiechtl, MD and Sheldon Jacobson, MD, FACEP, FACP
Publication Date: March 1, 2008

Excerpt from the issue…
You’re in the middle of a busy Monday afternoon shift. The next chart simply states “other complaint,” but one look at the patient tells you why he is here. The patient is a middle-aged male with no prior medical history who states that his family has been telling him his eyes are yellow for the last two to three weeks. He initially thought nothing of it but became concerned when the discoloration spread to his face. He also admits to occasional nausea, vomiting, poor appetite, weight loss, and diffuse itching. There is no history of fever, abdominal pain, heavy alcohol use, or recent acetaminophen ingestion. The physical exam is remarkable for icteric sclerae, jaundice of his face and upper chest, and mild non-tender hepatomegaly. Your history and physical have helped to develop the differential diagnosis related to the patient’s presentation your challenge is directing the ED work-up so that the appropriate initial interventions can be made before disposition

Conclustion of the above case study...
Your patient’s lab profile was significant for elevated direct bilirubin and alkaline phosphatase as well as mildly elevated transaminases, consistent with biliary obstruction. Based on the history and physical, you were more concerned about a malignant obstruction, so you ordered a CT of the abdomen and pelvis with contrast. This study showed a distended gallbladder with no cholelithiasis, a dilated common bile duct, and a mass at the head of the pancreas. Surgery was called and you made arrangements to admit the patient for ERCP and biliary decompression. You informed the patient of the CT results and let him know that he would be admitted for further work-up of the mass.

About this article:
Whether jaundice is the presenting complaint or an incidental physical finding, it requires the emergency physician (EP) to be an astute diagnostician. Because the differential is so broad, a thorough history and physical examination must be performed—a challenge in even a moderately busy department. The history and physical examination will help narrow the differential diagnoses, driving the work-up and disposition.

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