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A 67-year-old man with type 2 diabetes presents to your primary care practice following 3 weeks of intermittent nausea and vomiting. His wife insisted he see a doctor because his skin and eyes are yellow. He has noticed that his pants are looser, but he has no other complaints.
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- What are other important questions to ask this patient?
- What is the differential diagnosis of jaundice? Of painless jaundice?
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Jaundice is a yellow discoloration of body tissues due to an excess of bilirubin, a pigment produced during the metabolism of heme. Normally, serum bilirubin should never exceed 1 to 1.5 mg/dL. Levels above 2 mg/dL result in detectable jaundice, first in the sclerae, next under the tongue and along the tympanic membranes, and finally in the skin. Thus, cutaneous jaundice implies higher levels of bilirubin than isolated scleral icterus.
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A thorough dietary and medication history can exclude the yellow skin discoloration of carotenemia, isotretinoin, or rifampin overdose, all of which spare the sclerae. Once these mimickers are excluded, jaundice must be recognized as a manifestation of advanced hepatocellular or cholestatic liver disease or, less commonly, hemolysis or abnormal bilirubin metabolism. The history should proceed in 2 parallel routes: (1) arrive rapidly at a likely diagnosis and (2) identify alarm features that may necessitate urgent intervention.
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