What should be done regarding abnormal medical results?

Management of Abnormal Medical Test Results

Do not simply repeat abnormal tests to see if they normalize—immediately investigate the underlying cause with a comprehensive etiologic workup unless you have high clinical certainty the abnormality is transient from an identified acute insult. 1

Why Routine Repeat Testing Fails

The evidence against "wait and retest" strategies is compelling:

• 84% of abnormal results remain abnormal at 1 month, and 75% persist at 2 years, making routine repeat testing an inefficient approach that only delays diagnosis of treatable conditions 1
• Repeating tests postpones identification of conditions like hepatitis C, non-alcoholic fatty liver disease, and alcohol-related liver disease, which frequently present with mild elevations but can progress to end-stage disease 1
• The entire cost of repeat testing must be considered: patient recall, sample collection and transport, laboratory analysis, and most importantly, the clinical cost of delayed diagnosis 2

Immediate Actions Upon Discovering Abnormal Results

Step 1: Identify Red Flags Requiring Urgent Referral

• Unexplained clinical jaundice warrants immediate referral 2
• Suspicion of hepatic or biliary malignancy requires immediate specialist evaluation 2
• In children, maintain a low threshold for pediatric referral as the differential diagnosis is broader and common adult causes are less frequent 2

Step 2: Obtain Targeted Clinical Information

Before ordering additional tests, gather specific details that will guide your workup 2, 3:

• Age, ethnicity, and country of birth (to assess hepatitis B/C risk) 3
• Specific symptoms: jaundice, abdominal pain, weight loss, pruritus, fever, malaise, vomiting, right upper quadrant pain 3, 2
• Complete medication history: prescribed drugs, over-the-counter medications, herbal supplements 3
• Alcohol consumption and metabolic syndrome risk factors 3
• Physical examination findings: BMI, hepatosplenomegaly, ascites, signs of chronic liver disease 3

Step 3: Discuss Results with Laboratory and Patient

Before ordering confirmatory testing, have a direct conversation with both the laboratory/toxicologist and the patient 2:

• Explain that testing is intended to improve safety and guide appropriate management 2
• Ask patients about medication adherence, recent changes in health status, or exposures that might explain results 2
• This discussion can sometimes yield explanations that obviate expensive confirmatory testing 2
• Discussion with the laboratory can clarify technical issues, metabolite patterns, or cross-reactivities 2

Step 4: Order Appropriate Confirmatory or Etiologic Testing

Only test for substances or conditions where results will directly affect patient management 2:

• For abnormal liver tests, order a core etiologic panel immediately: complete blood count, comprehensive metabolic panel, hepatitis B surface antigen, hepatitis C antibody, anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody, serum immunoglobulins, simultaneous ferritin and transferrin saturation, and abdominal ultrasound 1
• If ALT >1000 U/L, add hepatitis A serology, hepatitis E serology, and cytomegalovirus testing 1
• For drug testing, use confirmatory methods (gas or liquid chromatography/mass spectrometry) only when initial results are unexpected and unexplained after patient discussion 2

Using Results to Improve Patient Outcomes

The primary goal is to use abnormal results to enhance patient safety and guide treatment decisions 2:

• Change pain management strategy if indicated 2
• Taper or discontinue medications causing harm 2
• Increase monitoring frequency for high-risk patients 2
• Offer harm reduction interventions (e.g., naloxone for opioid patients) 2
• Refer for treatment of substance use disorder or specialist care as appropriate 2

Critical Pitfalls to Avoid

• Never dismiss patients from care based solely on abnormal test results, as this constitutes patient abandonment and creates safety risks including patients seeking alternative sources or missing treatment opportunities 2
• Don't assume mild elevations are insignificant—many serious chronic conditions present with only mild abnormalities 1
• Don't stop investigating if tests normalize—normal results do not exclude chronic disease like hepatitis C or NAFLD 1
• Don't attribute abnormalities to medications without proper investigation, as 84% of "transient" abnormalities persist 1
• Recognize that the magnitude of abnormality does not necessarily correlate with clinical significance—context and specific analyte matter more than degree of elevation 2

When Repeat Testing Is Justified

Repeating tests without further workup is only appropriate when you have high clinical certainty the abnormality will resolve in response to an identified acute insult such as 1:

• Recent viral illness with expected resolution timeline
• Documented muscle injury causing enzyme elevation
• Short-term medication exposure that has been discontinued

In all other cases, proceed directly to etiologic investigation rather than passive observation.