Health Simulation Activity
Jaundice

Introduction

A man and women are waiting in the examination room with their one year old child balanced on one knee as a Doctor and intern walk into the room. The Dr. looks at the exterior physical appearance of the young child and asks the intern.

"What do you notice?"

The intern knew this question would be coming and began observing the child by first noticing the child's curly dark hair, tan skin, dark eyes with the whites (sclera) being bright yellow.

After seeing the yellow glow of the sclera (white part) in the eye the intern immediately thought and answered ... (1)

The Dr. reached for the child's hand and looked closer at both sides of the hand and spent more time looking at the finger nails.

The intern thought the Dr. was .... (2)

When the Dr. confirmed that there was a yellow tint in the skin and under the finger nails she asked the parents ... (3)

"Yesterday."

Doctor, "Has it happened before?"

Parent, "When he was born he was yellow for a few days and then it went away."

Doctor, "Has he been eating and drinking?"

Parent, "Yes."

The intern knew the jaundice was caused by something and began to search his memory for the cause of jaundice ... (4)

... and

What might be going on to increase the bilirubin levels? ... (5)

The Doctor continued to examine the child. Listened to the heart and found it had a rapid beat and the lungs sounded clear of fluid.

The intern thought the reason the Doctor examined these was to ... (6)

Next the Doctor used her fingers to probe the upper right side of the patient's abdomen to ... (7)

The child didn't show any signs of discomfort.

The Doctor asked, Did the child's diapers showed any unusual coloration?'

The parents answered, "Yes, it was a dark-orange color in his diapers."

The intern connected the orange urine as resulting from ... (8)

Next the Doctor looked closer at the child's eyes behind the eyelids, the eyelids themselves, lips, and behind and around the finger nails and decided they were paler than what they should be. Suggesting ... (9)

This examination suggested to try and verify or rule out anemia by ... (10) and

To investigate a cause of anemia by using the possible causes: malaria, inherited genetic condition, iron deficiency, vitamin B-12 deficiency, folate deficiency, bleeding, cancers that affect the bone marrow (such as leukemia), kidney disease, liver disease, hypothyroidism thalassemia — a genetic disorder that causes low levels of hemoglobin and red blood cells,

And ask questions such as ... (11)

Questioning resulted in negative answers to all questions except recent diet changes, which was answered with him eating fava beans two days ago.

Favism can be caused by eating broad beans. Beans that cause hemolysis (destruction of red blood cells) in people with Glucose-6-phosphate dehydrogenase deficiency (G6PD). However, not all people with G6PD deficiency have favism. It is more likely in infants and children. It is an X-linked recessive genetic condition that that can trigger hemolysis (spontaneous destruction of red blood cells) and result in jaundice as a response to certain foods, illness, or medication. It is most common in people of Mediterranean and African origin. Only know treatment is to avoid known triggers. Source

Immediate treatment with ... (12)

Test results. Blood test showed the hemoglobin was extremely low, about one-third a normal level for his age. Later tests revealed Glucose-6-phosphate dehydrogenase deficiency (G6PD).

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Hints and suggestions

  1. Jaundice
  2. Confirming the yellow tint by looking closer at the skin and finger nails for a yellow tint.
  3. When did the yellow appear?
  4. Jaundice is caused by too much bilirubin (a substance that results from breaking down red blood cells) that tints the skin and nails yellow. Jaundice in newborns needs to be monitored, because if bilirubin levels get too high (hyperbilirubinemia) it must be treated and lowered or it can cause brain damage (kernicterus) and other serious problems.
  5. To generate possible causes think about red blood cells. Where they are produced, their function, how they travel, and other organs that interact with them (filter blood ...). Some possibilities:
    1. Hemoglobin in the red blood cells could be malfunctioning, raising the bilirubin levels.
    2. Red blood cells might be being destroyed by white blood cells, pathogens, or toxins, raising the bilirubin levels.
    3. Liver might not be functioning well, which would increase bilirubin levels in the bloodstream since the liver wasn't removing bilirubin from the blood.
    4. Bile ducts might not be functioning which would decrease bilirubin from being excreted into the gastrointestinal tract and instead back up into the bloodstream.
  6. See if the condition was threatening life necessary functions.
  7. See if she could feel the liver or if the child showed signs of discomfort. If she could it would suggest the liver was enlarged, inflamed, or his bile ducts were blocked.
  8. Urine is produced in the kidney. Suggesting the color as a result of something in the blood stream that is passing through the kidney. Which could be hemoglobin from destroyed red blood cells passing through the kidney's filters and into the urine. While the coloring could be caused by liver or bile disease the physical exam of the area around the liver suggested it was not a bile or liver related problem.
  9. Anemia. Caused by a reduction of red blood cells, which would decrease the intensity of the red color. Anemia could also increase the heart rate because ... (the heart needs to pump faster to supply sufficient oxygen and remove carbon dioxide.)
  10. Verification of anemia with a blood test to find hemoglobin levels
  11. Has he been exposed to mosquitoes that might have given him malaria? Is there a history of anemia in the family? Have they feed any new food to their son lately?
  12. To begin treatment with a blood transfusions. Before a blood transfusion can be given, what must be determined or considered?
    (Blood types and antigens)

Adapted from Yellow for Caution by Jonathan Reisman Discover Magazine May 2016.