How to write in general examination column saying that, patient has jaundice, the eyes are yellowish
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Here is how to document jaundice with icteric sclerae in the General Examination column of a clinical case sheet:
Standard Clinical Documentation
General Examination:
The patient is conscious, cooperative, and well-oriented to time, place, and person. On general examination, icterus is present — the sclera are icteric (yellowish discoloration of the conjunctival sclera noted bilaterally). Skin also shows yellowish tinge. [Note pallor/cyanosis/clubbing/lymphadenopathy/edema as present or absent separately.]
Shorter Formal Version (Common in Clinical Notes)
Icterus: Present — scleral icterus noted bilaterally.
Key Points
| Term | Meaning |
|---|---|
| Icterus | The clinical term for jaundice detected on examination |
| Scleral icterus | Yellowish discoloration of the white of the eyes (conjunctival sclera) — earliest and most reliable sign of jaundice |
| Visible at bilirubin ≥ 2–3 mg/dL | Scleral icterus appears before skin yellowing |
Full General Examination Template with Jaundice Included
General Examination:
- Built: moderately built and nourished
- Conscious, cooperative, well-oriented
- Icterus: Present (scleral icterus +, skin icteric)
- Pallor: Absent / Present
- Cyanosis: Absent
- Clubbing: Absent
- Lymphadenopathy: Absent
- Edema: Absent
- Pulse: 80 bpm, regular, normal volume and character
- BP: 120/80 mmHg
- RR: 18/min
- Temperature: Afebrile
- SpO₂: 98% on room air
Why "scleral icterus"? The sclera has a high affinity for bilirubin due to its elastin content, making it the earliest site to show yellowing — so always specifically mention the eyes when documenting jaundice.
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