Question

Part III – Something's Not Right

“It’s good to have you home, honey. I missed you. How was the flight?” Stacey had come to the airport to pick Frank up and she leaned over to kiss him as he climbed into the car with his luggage. “How were the meetings? You look tired,” she added.

“The past week was intense and I am exhausted. I thought I would manage some R & R during the trip, but no such luck. John and Dan were fired and we were told that there would be more layoffs in the future if business doesn’t pick up. Everyone is feeling stressed. “

“You’re one of the hardest workers they have Frank, they can’t let you go.”

“I hope you’re right. They gave us tomorrow off in lieu of making us work for 7 days straight, but I can’t help but think I should go in and get a jump on the week.”

“I know you don’t want to hear this, but you have an appointment for that glucose tolerance test first thing in the morning. We’ll need to eat soon because the instructions say you are not allowed to eat for 8 hours before the test.”

Frank felt miserable. “I’m really not hungry. Maybe it was the change in diet, but I’ve had a persistent stomach ache and I didn’t eat much when I was away.

“Well, we need to take extra special care of you until we find out what’s wrong. I am sure everything’s going to be okay.”The next morning the alarm went off and Frank felt refreshed after a good night’s sleep.

“What’s the matter Stacey? You look like you’ve seen a ghost.”

Stacey brought him her pocket mirror so that he could see for himself. “Forget the glucose tolerance test. I think we need to go to the Emergency Room right now.”

* ************

Doctor Smithers looked into Frank’s eyes. “It’s a good thing you came in because even a first year medical student could see that you are jaundiced.”

Stacey looked concerned. “What does that mean? Is he going to be okay?”
“Well it could mean a few different things,” replied the doctor, “so we are going to have to run some tests to be sure.”

Fill in Flow Chart 1 with the best choices from the provided word list.

Questions

5. Use Flow Chart 1 to suggest possible reasons for Frank’s jaundiced appearance.

6. Do you think that Frank’s jaundice is connected to the high blood glucose levels seen on the morning before his business trip? Why or why not?

7. Would you like to make a diagnosis to explain Frank’s jaundiced appearance?

8. What tests would you run to determine or confirm any of your diagnoses?

Part IV – The Test Results

“What does it mean to be jaundiced, doctor? Why did the whites of my eyes turn yellow?” “It’s usually caused by a high level of a molecule called bilirubin in your blood, Frank.”
“I was a biology major in college, but I don’t remember where bilirubin comes from.”

“Your blood has cells called erythrocytes or red blood cells; they contain hemoglobin which gives blood its red color. Cells in the spleen break down red blood cells and the products are reused by your body. The heme portion of hemoglobin is converted to bilirubin, which is the molecule that is responsible for your yellow color.”

“I remember now, isn’t bilirubin involved in digestion?”

“Yes. Bilirubin leaves the spleen in the blood and, because it’s not soluble in water, it binds with blood proteins called albumens to form unconjugated bilirubin. This bilirubin is taken up by the cells in the liver, where it combines with glucuronic acid to form conjugated bilirubin. It is one component of the bile, which travels down the bile duct to the gall bladder and the small intestine. When you eat, the gall bladder contracts and pushes the stored bile into the small intestine to aid in the digestion of fat.”

“So what do my tests show?”
“Your hematocrit and your liver enzymes are at normal levels.” “So, my liver’s okay?”

“These enzymes are normally confined to the liver cells and would only be found in large amounts in the blood if your liver was damaged. So these results indicate that there is no liver damage; that’s good. But I am concerned that there is tenderness in the upper left quadrant of your abdomen ... sorry, around your stomach,” the doctor smiled at Frank and Stacey.

“As I explained before, a jaundiced appearance is often produced by a buildup of bilirubin in the blood and your results confirm this (Table 3).”

Table 3 – The Level of Bilirubin in Blood

Bilirubin Type	Frank’s Blood	Normal Blood
unconjugated	0.9 mg/dl	0.3 – 1.6 mg/dl
conjugated	0.6 mg/dl	0 – 0.3 mg/dl

“One more thing concerns me,” continued the doctor. “There is almost no urobilinogen or urobilin in your urine.”

“What are they?” asked Frank.

“Bacteria in your intestines change bilirubin to urobilinogen. This urobilinogen can be reabsorbed back into your body and some is converted to urobilin. These two molecules circulate in your blood and are excreted in your urine; it is the urobilin that produces the straw color of urine. The low level of these two molecules in your urine plus the high level of bilirubin in your blood and the pale color of your stools indicates to me that, for some reason, bilirubin is staying in your body instead of going into your intestines.”

Questions

1. Where is unconjugated bilirubin formed?
2. Is the level of unconjugated bilirubin in Frank’s blood within the normal range? 3. Where is conjugated bilirubin formed?
4. Is the level of conjugated bilirubin in Frank’s blood within the normal range?

5. Using Flow Chart 1, outline some possible reasons for the high level of conjugated bilirubin; remember Frank’s liver enzymes are normal.

6. Frank experienced tenderness in the upper left quadrant of his abdomen. Use the word list in Figure 1 to label the major organs in this area.

7. Consider your diagnosis for Frank’s high blood glucose levels. Which gland secretes insulin?

8. Which organs are involved in creating Frank’s jaundiced appearance?

9. Look at Figure 1 and determine whether this gland and these organs (answers to Questions 7 and 8) are connected in any way.

10. Can you think of a reason that would explain the high levels of glucose and conjugated bilirubin in Frank’s blood?

11. Would you like to make any adjustments to your diagnoses?

Answer 1