QUATERNARY PREVENTION IN PRIMARY CARE - A CASE REPORT

Introduction and Objectives: quaternary prevention is defined as the detection of individuals at risk of overtreatment in order to protect them from inappropriate new medical interventions. The aim of this report is to describe the clinical investigation of a patient with unconjugated hyperbilirubinemia. Methods: A male patient, 68 years old, consulted a dermatologist for an evaluation of melanocytic nevi. It had been decided to perform a surgical removal of the lesions and to this end, the especialist asked numerous pre-operative tests, among which were the serum bilirubin, which values were 2.04 mg/dl (total bilirubin) and 1.54mg/dl (indirect bilirubin). Since the patient had gotten worried about the altered results, he went to a primary care physician for clarification. Additional upper abdomen ultrasound and liver function tests confirmed the diagnosis of Gilbert‘s syndrome. Results and Conclusions: Gilbert‘s syndrome, a recessive inheritance pathology, is characterized by chronic and recurrent indirect hyperbilirubinemia. Among its precipitants for jaundice and hyperbilirubinemia are: gastrointestinal bleeding, physical activity and long periods of fasting. Nevertheless, the disease has a purely benign prognosis and appears to be more prevalent in men (4 times more than in women). The primary cause is a defect in UDP Glucuronyl transferase enzyme, which performs the glucuronidation of bilirubin. This report illustrates that tests ordered inappropriately may result in increased anxiety for patients, increased costs from the health system, which would result in overdiagnosis. Thus, it is essential for the family physician to pay attention to the quaternary prevention in order to protect the patient’s interests.