Evaluation of Jaundice in Adults.

Jaundice in adults can be an indicator of significant underlying disease. It is caused by elevated serum bilirubin levels in the unconjugated or conjugated form. The evaluation of jaundice relies on the history and physical examination. The initial laboratory evaluation should include fractionated bilirubin, a complete blood count, alanine transaminase, aspartate transaminase, alkaline phosphatase, ?-glutamyltransferase, prothrombin time and/or international normalized ratio, albumin, and protein. Imaging with ultrasonography or computed tomography can differentiate between extrahepatic obstructive and intrahepatic parenchymal disorders. Ultrasonography is the least invasive and least expensive imaging method. A more extensive evaluation may include additional cancer screening, biliary imaging, autoimmune antibody assays, and liver biopsy. Unconjugated hyperbilirubinemia occurs with increased bilirubin production caused by red blood cell destruction, such as hemolytic disorders, and disorders of impaired bilirubin conjugation, such as Gilbert syndrome. Conjugated hyperbilirubinemia occurs in disorders of hepatocellular damage, such as viral and alcoholic hepatitis, and cholestatic disorders, such as choledocholithiasis and neoplastic obstruction of the biliary tree.

Brugada syndrome unmasked by fever.

Brugada syndrome (BS) is a cardiac rhythm disturbance that predisposes patients to sudden cardiac death. Brugada is classically described with specific electrocardiographic (EKG) findings of ST elevation and right bundle branch block in precordial leads and is an often unrecognized contributor to sudden cardiac death. We present a case of BS with cyclic EKG findings in a febrile 20-year-old active duty, Vietnamese male who presented following a witnessed syncopal event. His classic findings of Brugada pattern on EKG demonstrated reversibility with clinical defervescence. In patients with a suggestive history, a normal EKG cannot definitively rule out BS as the Brugada pattern can be unmasked by stress, which in this case was represented by a pneumonia-induced fever.