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PreMedEaz PreClinEazy y SurgEazy FinalsEazyOSCEazy NISH DALAVAYE THE DATA INTERPRETATION STATION PART 3 SESSION TIME: 30 mins Role F1 Setting Emergency department Patient Mr Pi, a 42 y/o male presented with dehydration Student tasPlease interpret the data presented in a systematic manner STUDENT INSTRUCTIONS PLEASE INTERPRET THIS DATA RENAL FUNCTION TESTS In A&E 6 hours later NORMAL RANGE Explain the changes after 6 hours Sodium 144 mmol/L 130 mmol/L 135-146 mmol/L Potassium 4.5 mmol/L 5.2 mmol/L 3.2 – 5.1 mmol/L Urea 4.8 mmol/L 10.8 mmol/L 1.7-8.3 mmol/L What is the significance of the raised glucose, ferritin and lactate? Creatinine 70 μmol/L 105 μmol/L 62-106 μmol/L Glucose - 8 mmol/L <5.5 mmol/L Lactate - 4.2mmol/L 0.5-1 mmol/L Ferritin - 853 μg/L 30-400 μg/L STAGING AKI ABRUPT & SUDDEN DECREASE IN KIDNEY FUNCTION ‘Kidney Disease: Improving Global Outcomes’ (KDIGO) criteria: AKI Definition AKI Staging Serum creatinine ≥26.5 μmol/L increase within 48 hours Rise in serum creatinine >26.5μmol/L OR STAGE 1 Serum creatinineOR.5–1.9 times baseline within 7 days within 48 hours Urine output <0.5 ml/kg/h for 6–12 hours OR Serum creatinine 2-2.9 times baseline STAGE 2 OR Rise in serum creatinine >1.5x Urine output <0.5 ml/kg/h ≥ 12 hours Serum creatinine ≥353.6 μmol/L baseline within 7 days OR Serum creatinine ≥ 3 times baseline OR OR STAGE 3 Initiation of renal replacement therapy Urine output <0.5ml/kg/h for Urine output < 0.3 mL/kg/h for ≥ 24 h or >6 consecutive hours OR Anuria for ≥ 12 h Role Medical Student Setting GP Patient Mr Miyagi, a 42 y/o male has a history of polycystic kidney disease and has presented for renal function tests. Student tasPlease interpret the data presented in a systematic manner STUDENT INSTRUCTIONS PLEASE INTERPRET THIS DATA RENAL FUNCTION TESTS PATIENT VALUE NORMAL RANGE Haemoglobin 10.8 g/dL 13.5–18.0 g/dL White blood cells 10.9 × 10 /L 4.0-11.0 x 10 /L What stage of renal failure do you consider him to be? Mean cell volume 73 fL 76-100 fL Ferritin 25 μg/L 30-400 μg/L Transferrin saturation 4% 5-50% What is the type and cause of his anaemia? Sodium 140 mmol/L 135-146 mmol/L Potassium 6.3 mmol/L 3.2 – 5.1 mmol/L Urea 21.7 mmol/L 1.7-8.3 mmol/L Explain the causes of his low calcium, high phosphate & PTH? Creatinine 350 μmol/L 62-106 μmol/L eGFR 17 mL/min/1.73m2 >60 mL/min/1.73m2 Calcium (adjusted) 1.8 mmol/L 2.15-2.55 mmol/L What are the causes of hyperkalaemia? Phosphate 2.6 mmol/ 0.87-1.45 mmol/L Parathyroid hormone 250 ng/L 15-65 ng/L STAGING CKD 120 / 0 CKD STAGE eGFR 2 15 (ml/min/1.73m ) G5 G1 >90 G1 G4 G2 60-89 30 90 G3a 45-59 G3b G2 G3b 30-44 G3a 45 G4 15-29 60 G5 <15 ‘’eGFR CLOCK’’ IRON STUDIES Anaemia of Iron deficiency chronic disease anaemia Haemoglobin ↓ ↓ Serum Iron (Fe) ↓ ↓ Ferritin ↑ ↓ Transferrin saturation Normal/ ↓ ↓ Total iron binding capacity (TIBC) ↓ ↑ Red blood cell distribution width (RBW) Normal ↑ ALKALINE PHOSPHATASE PARATHYROID HORMONE CALCIUM PHOSPHATE (ALP) (PTH) OSTEOPOROSIS NORMAL NORMAL NORMAL NORMAL MULTIPLE MYELOMA HIGH VARIABLE NORMAL / LOW LOW PAGET’S DISEASE OF THE BONE NORMAL NORMAL VERY HIGH NORMAL PRIMARY HYPERPARATHYROIDISM HIGH LOW HIGH HIGH SECONDARY NORMAL/ HYPERPARATHYROIDISM LOW/ NORMAL HIGH in renal failure HIGH HIGH TERTIARY HYPERPARATHYROIDISM HIGH HIGH HIGH HIGH LOW HIGH LOW LOW HYPOPARATHYROIDISM OSTEOMALACIA LOW LOW HIGH HIGH Causes of Hyperkalaemia Pseudo- Impaired excretion Extracellular Shift Increased Intake Hyperkalaemia + K K + K + K + Cells • Acute kidney injury • Beta-Blockers • Excess oral potassium supplement• Prolonged use of a tourniquet • Chronic kidney disease • Metabolic Acidosis • Excess potassium containing IV infusionsclenching during blood withdrawal • Hypoaldosteronism • Haemolysed sample • Hypercortisolism • Digoxin • Sample from a limb receiving IV • Renal tubular acidosis type 4• Lysis (Tumour lysis syndrome, Rhabdomyolysis) potassium • HyperOsmolality • Drugs (e.g. ACE-inhibitors, N•AISugar (Diabetic Ketoacidosis) • Succinylcholine Role Medical Student Setting GP Patient Mr Thalapathy, a 42 y/o male has presented with an acute asthma exacerbation. Student tasPlease interpret the data presented in a systematic manner STUDENT INSTRUCTIONSPLEASE INTERPRET THIS DATA NEWS CHART NEWS SCORE = 9 CLASSIFYING ASTHMA SEVERITY SEVERE LIFE-THREATENING NEAR-FATAL • Inability to complete sentences• Arrhythmia one breath • Confusion, Cyanosis • Hypotension • Exhaustion CLINICAL FEATURES • Silent chest Raised PaCO2 and/or requiring • Tachycardia mechanical ventilation with raised • Respiratory r≥ 25/min • PaO2 <8 kPa inflation pressures VITAL SIGNS • Heart rate ≥ 110/min • Normal PaCO2 OXYGEN SATURATIONS ≥ 92% < 92% PEFR 33-50% <33% PLEASE INTERPRET THIS DATA ARTERIAL BLOOD GAS PATIENT NORMAL PATIENT NORMAL PATIENT NORMAL PATIENT NORMAL VALUE RANGE VALUE RANGE VALUE RANGE VALUE RANGE pH 7.32 7.35 – 7.45 pH 7.42 7.35 – 7.45 pH 7.21 7.35 – 7.45 pH 7.45 7.35 – 7.45 pCO 8 4.7 – 6 kPa pCO 2 13 4.7 – 6 kPa pCO 4 4.7 – 6 kPa pCO 3 4.7 – 6 kPa 2 2 2 HCO - 32 22 - 30 mmol/L HCO 3 40 22 - 30 mmol/L HCO - 10 22 - 30 mmol/L HCO - 18 22 - 30 mmol/L 3 3 3 RESPIRATORY ACIDOSIS WITH PARTIAL METABOLIC ALKALOSIS WITH FULL METABOLIC ACIDOSIS WITH PARTIAL RESPIRATORY ALKALOSIS WITH FULL METABOLIC COMPENSATION RESPIRATORY COMPENSATION RESPIRATORY COMPENSATION METABOLIC COMPENSATION COMMON CAUSES OF COMMON CAUSES OF COMMON CAUSES OF COMMON CAUSES OF RESPIRATORY ACIDOSIS METABOLIC ALKALOSIS METABOLIC ACIDOSIS RESPIRATORY ALKALOSIS • COPD • Vomiting • Anxiety, panic attacks High anion gap Normal anion gap • Asthma • Loop/ Thiazide diuretics metabolic acidosis:metabolic acidosis: • Pregnancy • Ketoacidosis • Diarrhoea • Acute respiratory disease • Hyperaldosteronism • Ingestions • Ureteral diversion • High altitude • Respiratory muscle weakness • Cushing’s syndrome • Lactic acidosis • RTA • Uraemia • Hyperalimentation • Aspirin toxicity • CNS depression • Addison's disease • MiscellaneousHIGH BASE EXCESS (> +2mmol/L) = METABOLIC ALKALOSIS/ TYPE 1 RESPIRATORY FAILURE = Low PaO2 with normal/low PaCO2 COMPENSATED RESPIRATORY ACIDOSIS INTERPRETING ABGs TYPE 2 RESPIRATORY FAILURE = Low PaO2 < 8kPa with high PaCO2 LOW BASE EXCESS (< - 2mmol/L) = METABOLIC ACIDOSIS/ COMPENSATED RESPIRATORY ALKALOSIS pH pH < 7.35 pH > 7.45 ACIDOSIS ALKALOSIS - - ↑ PaCO2 ↓ HCO3 ↓ PaCO2 ↑ HCO3 RESPIRATORY METABOLIC METABOLIC RESPIRATORY ACIDOSIS ACIDOSIS ALKALOSIS ALKALOSIS ↑ HCO3- ↓ PaCO 2 ↓ HCO3- ↑ PaCO2 METABOLIC RESPIRATORY METABOLIC RESPIRATORY COMPENSATION COMPENSATION COMPENSATION COMPENSATION NORMAL pH = HEALTHY OR FULL COMPENSATION ABNORMAL pH = NONE OR PARTIAL COMPENSATION PLEASE INTERPRET THIS DATA PEAK FLOW 400 300 PEFR (L/MIN) 200 100 Diurnal variation 0 1 2 3 4 5 6 DAY PLEASE INTERPRET THIS DATA SPIROMETRY VOLUME (L) • Forced expiratory volume in 1 second (FEV1) = 60% of predicted, • Forced vital capacity (FVC) = 57% of predicted, • FEV1/FVC = 0.84 • No improvement after administration of beta-2 agonist NORMAL • Transfer factor = reduced DESCRIBING SPIROMETRY PATIENT • NAME, AGE, • WHAT IS DATA REPRESENTING • QUALITY OF SPIROMETRY • NUMBER OF BREATHS TAKEN INTERSTITIAL LUNG DISEASE • FEV1 (% predicted) • FVC (% predicted) • FEV1/FVC • PRE & POST BRONCHODILATOR • SHAPE OF CURVES • OBSTRUCTIVE OR RESTRICTIVE • LIKELY DIAGNOSIS 1 TIME (SECONDS) TIDAL VOLUME Volume of air inspired & expired VOLUME LUNG VOLUMES & CAPACITIES during quiet breathing INSPIRATORY RESERVE VOLUME Maximum volume of air inspired above tidal volume EXPIRATORY RESERVE VOLUME INSPIRATORY RESERVE VOLUME (3L) Maximum volume of air expired below tidal volume INSPIRATORY CAPACITY RESIDUAL VOLUME VITAL (3.5L) Volume of air remaining in lungs CAPACITY after maximal expiration TIDAL VOLUME (500ml) (4.7L) TOTAL LUNG INSPIRATORY CAPACITY CAPACITY (5.9L) TV + IRV EXPIRATORY RESERVE (1.2L) VOLUME FUNCTIONAL FUNCTIONAL RESIDUAL CAPACITY RESIDUAL ERV + RV CAPACITY (1.2L) RESIDUAL VOLUME (2.4L) VITAL CAPACITY TV + IRV + ERV TIME TOTAL LUNG CAPACITY TV + IRV + ERV + RV LUNG DISEASE OBSTRUCTIVE RESTRICTIVE COPD INTERSTITIAL LUNG DISEASES ASTHMA OBESITY BRONCHIECTASIS CHEST/ SPINE DEFORMITIES CYSTIC FIBROSIS RESPIRATORY MUSCLE WEAKNESS INTERPRETING SPIROMETRY VOLUME (L) OBSTRUCTIVE LUNG DISEASE NORMAL FEV1: reduced (much more than FVC) FORCED VITAL CAPACITY (FVC) FVC: may be normal but often reduced FEV1/FVC: < 70% Significant improvement in FEV1with bronchodilators = asthma RESTRICTIVE FORCED EXPIRATORY VOLUME IN 1 SECOND I E (FEV1) RUC T OB ST RESTRICTIVE LUNG DISEASE FEV1: reduced FVC: reduced FEV1/FVC: NORMAL OR > 80% TIME (SECONDS) 1 INTERPRETING FLOW-VOLUME LOOPS FLOW (L/s) NORMAL 8 PEFR RESTRICTIVE OBSTRUCTIVE EXPIRATION OBSTRUCTIVE LUNG DISEASE 4 Residual volume: Increased Total lung capacity: Increased VOLUME (L) 8 7 6 5 4 3 2 1 0 RESTRICTIVE LUNG DISEASE Residual volume: Reduced 4 INSPIRATION Total lung capacity: Reduced VITAL CAPACITY RESIDUAL VOLUME 8 TOTAL LUNG CAPACITY TRANSFER FACTOR (TLCO) OBSTRUCTIVE LUNG DISEASE RESTRICTIVE LUNG DISEASE OTHER • Emphysema • Interstitial lung disease • Anaemia ↓ TLCO • Pulmonary oedema • Pulmonary hypertension • Postpneumonectomy • Pulmonary embolism • Chronic bronchitis • Pleural disorders Normal • Asthma • Respiratory muscle TLCO • Bronchiectasis weakness • Cystic fibrosis • Thoracic cage deformities ↑ TLCO • Asthma • Obesity • Polycythaemia Role Medical Student Setting GP Patient Mrs Heard, a 36 y/o woman is unwell Student tasPlease interpret the data presented in a systematic manner STUDENT INSTRUCTIONS MALIGNANT EFFUSION • Appearance = Blood stained PLEASE INTERPRET • Pleural protein content = 40g/L • Pleural fluid protein : serum protein ratio = 0.78 THIS DATA • Negative gram stain serum LDH ratio = 0.81 PLEURAL FLUID ANALYSIS • Negative cultures • Abnormal cytology • Low glucosePLEURAL FLUID ANALYSIS TRANSUDATE EXUDATE Congestive heart failure Malignancy (commonly breast or lung) Liver cirrhosis Infection (parapneumonic effusion, tuberculosis, empyema) Common causes Nephrotic syndrome Infarction (Pulmonary embolism) Severe hypoalbuminaemia Inflammation (SLE, Rheumatoid arthritis) Total protein < 30 g/L > 30 g/L Pleural fluid protein/ serum protein ratio ≤ 0.5 > 0.5 Pleural fluid LDH/ ≤ 0.6 > 0.6 Light’s Criteria serum LDH ratio Pleural fluid LDH < ⅔ the upper limit of normal serum LDH > ⅔ the upper limit of normal serum LDH WBC count < 1000 cells/µL (typically) > 50,000 cells/µL (typically) Low glucose (<3.3 mmol/L) Malignancy, Empyema/ complicated parapneumonic effusion, RheumatoidArthritisand Tuberculosis (‘MEAT’) pH < 7.2 High amylase Pancreatitis Abnormal cytology Malignancy Positive acid fast bacilli Tuberculosis Neutrophil dominant Empyema/ complicated parapneumonic effusion Lymphocyte dominant Tuberculosis, Malignancy, Chylothorax RESOLVED HEPATITIS B INFECTION • HBsAg: Negative PLEASE INTERPRET • Anti-HBs: Positive THIS DATA • Anti-HBc (IgG): Positive HEPATITIS B SEROLOGY • Anti-HBc (IgM): Negative • HBeAg: Negative • Anti-HBe: Negative HEPATITIS B SEROLOGY HEALTHY ACUTE ‘WINDOW CHRONIC CHRONIC CURED DUE TO CURED DUE TO (no exposure or INFECTION INFECTION PRIOR PRIOR vaccination) INFECTION PERIOD’ (ACTIVE) (INACTIVE) INFECTION VACCINATION HBsAg ACTIVE = HBeAg INACTIVE = Anti-HBc(IgM) Anti-HBc(IgG) VARIABLE Anti-HBe VARIABLE Anti-HBs OBSTRUCTIVE JAUNDICE PATIENT VALUE NORMAL RANGE ALT 140 10 - 50 IU/L AST 125 10 - 40 IU/L ALP 358 25 - 115 IU/L PLEASE INTERPRET GGT 129 9 - 40 U/L THIS DATA BILIRUBIN 158 < 17 µmol/L LIVER FUNCTION TESTS LIVER FUNCTION TESTS ↑ALT ↑ AST ↑ ALP ↑ GGT HEPATOCELLULAR CHOLESTASIS/ DAMAGE OBSTRUCTION ALP IS ALSO FOUND IN BONE TISSUE & PLACENTA ISCHAEMIC TRUE MEASURES OF LIVER FUNCTION HEPATITIS PROTHROMBIN TIME/ INR BILIRUBIN ALT > 1000 IU/L ALBUMIN CAN SOMETIMES OCCUR WITH ACUTE VIRAL HEPATITIS PLATELETS & AUTOIMMUNE HEPATITS PARACETAMOL GLUCOSE OVERDOSE PRE-HEPATIC JAUNDICE HEPATOCELLULAR JAUNDICE POST-HEPATIC JAUNDICE CAUSE Excess unconjugated bilirubinImpaired conjugation of Damage to hepatocytesimpaired Biliary obstruction production unconjugated bilirubin conjugation & reduced bilirubin excretion Haemolytic anaemia Gilbert’s syndrome Gallstone disease EXAMPLES Erythropoiesis disorders Crigler–Najjar syndrome Hepatocellular disease (e.g. hepatitis)PBC, PSC, Pancreatic cancer Biliary atresia UNCONJUGATED BILIRUBIN ↑↑ NORMAL ↑ CONJUGATED BILIRUBIN NORMAL ↑↑ URINARY BILIRUBIN NORMAL ↑ ↑↑ URINARY UROBILINOGEN ↑↑ NORMAL/ ↑ NEGATIVE URINE COLOUR NORMAL DARK URINE VERY DARK URINE STOOL COLOUR NORMAL NORMAL/ CLAY COLOURED STOOLS CLAY COLOURED STOOLS ALT, AST NORMAL ↑↑ NORMAL INITALLY (CAN↑ LATER ON) ALP, GGT NORMAL ↑ ↑↑ OTHER ↓ Hb , ↑ LDH, ↑ reticulocytes, ABDOMINAL ULTRASOUND ABDOMINAL ULTRASOUND INVESTIGATIONS ↓ haptoglobins Haemosiderinuria Gilbert ‘s Syndrome FEATURES OF LIVER DISEASE PANCREATIC CANCE à painless (intravascular haemolysiTransient jaundice triggered by stress, infection, fasting etc. jaundice, CA 19-9 Haemoglobinuria benign OTHER (intravascular haemolysis) FEATURES Crigler–Najjar Syndrome PBC à anti-mitochondrial antibodies Splenomegaly Persistent jaundice in first few (extravascular haemolysisdays of life. Risk of PSC à P-ANCA kernicterus. Treatment needed. Pigmented gallstones SUB -CLINICAL HYPOTHYROIDISM PLEASE INTERPRET PATIENT VALUE NORMAL RANGE THIS DATA TSH 5.1 0.4 - 4.1 mIU/L THYROID FUNCTION TESTS T4 0.9 0.8 - 1.8 ng/dL T3 2.2 2.0 - 3.5 pg/mL Anti-TPO antibodies positive HYPOTHALAMUS - PITUITARY – THYROID AXIS ↓ T4, ↓ T3, ↓ TSH, TERTIARY TERTIARY ↑ T4, ↑ T3, ↑ TSH, ↓ TRH HYPOTHYROIDISM HYPOTHALAMUS HYPERTHYROIDISM ↑ TRH TRH SECONDARY ANTERIOR ↓ T4, ↓ T3, ↓ TSH HYPOTHYROIDISM SECONDARY ↑ T4, ↑ T3, ↑ TSH, PITUITARY HYPERTHYROIDISM TSH ↓ T4, ↓ T3, ↑ TSH PRIMARY THYROID GLAND PRIMARY ↑ T4, ↑ T3, ↓ TSH HYPOTHYROIDISM HYPERTHYROIDISM Normal T4, SUBCLINICAL SUBCLINICAL Normal T4, Normal T3, HYPOTHYROIDISM FREE T4, FREE T3 HYPERTHYROIDISM Normal T3, ↓ TSH ↑ TSH ANTIBODIES IN THYROID DISEASE Anti-TSH receptor Anti-TPO Anti-Tg GRA VE’S PRESENT IN 90% PRESENT IN 70% PRESENT IN∼ 50–70% DISEASE HASHIMOTO’S PRESENT IN 10–15% PRESENT IN > 90% PRESENT IN > 80% THYROIDITIS CAN BE PRESENT IN CAN BE PRESENT IN POSTPARTUM THYROIDITIS THYROID CANCERPLEASE INTERPRET THIS DATA JOINT FLUID MICROSCOPY UNDER PLANE-POLARISED LIGHT GOUT NEEDLE-SHAPED, NEGATIVELY-BIREFRINGENT CRYSTALSPLEASE INTERPRET THIS DATA JOINT FLUID MICROSCOPY UNDER PLANE-POLARISED LIGHT PSEUDOGOUT RHOMBOID-SHAPED, POSITIVELY-BIREFRINGENT CRYSTALS JOINT ASPIRATE INTERPRETATION WBC CAUSES CLARITY COLOUR COUNT NEUTROPHIL CULTURE CRYSTALS 3 COUNT (/MM ) TRANSLUCENT COLOURLESS < 200 CELLS < 25 % NEGATIVE ABSENT NORMAL RHEUMATOID ARTHRITIS GOUT INFLAMMATORY JOINT PSEUDOGOUT TRANSLUCENT - OPAQUYELLOW 2000 – 75000 NEGATIVE PRESENT / ABSENT EFFUSION CELLS ≥ 50 % PSORIATIC ARTHRITIS PRESENT IN REACTIVE ARTHRITIS GOUT/ PSEUDOGOUT OSTEOARTHRITIS NON-INFLAMMATORY TRANSLUCENT < 2000 CELLS < 25 % NEGATIVE ABSENT JOINT EFFUSION TRAUMA STRAW-LIKE SEPTIC JOINT S.AUREUS EFFUSION OPAQUE YELLOW-GREEN >50000 CELLS ≥ 75 % POSITIVE ABSENT N. GONORRHOEAE BLEEDING DISORDER BLEEDING JOINT BLOODY RED < 2000 CELLS EFFUSION TRAUMA 50 - 75 % NEGATIVE ABSENT IATROGENIC PATIENT VALUE NORMAL RANGE SPECIFIC GRAVITY 1.001 g/dL 1.010 – 1.030 pH 6.6 4.5-8 PROTEIN NONE BLOOD NEGATIVE GLUCOSE NEGATIVE KETONES NEGATIVE LEUKOCYTE ESTERASE NEGATIVE PLEASE INTERPRET NITRITES NEGATIVE THIS DATA URINALYSIS • Patient complains of polyuria • Family history of sickle cell disease & early-onset SICKLE -CELL TRAIT stroke SICKLE CELL NEPHROPATHY CORTEX MEDULLA DELAYED FREE WATER VASA RECTA REABORPTION & COUNTER CURRENT ↓ O2 EXCHANGE ↓ pH = SICKLING = ↑ Osmolarity HYPOSTHENURIA URINALYSIS INTERPRETATION - Normal range = 4.5 - 8 pH - High pH –Vegetarian diet, UTI etc - Low pH – Starvation, Diabetes Mellitus, high protein diet - Raised in hyperglycaemia e.g. Diabetes Mellitus, Cushing’s Syndrome GLUCOSE - Raised in reduced renal absorption e.g. Renal Tubular Acidosis, SGLT -2 inhibitors - Raised in Diabetic Ketoacidosis, starvation KETONES - Indicative of the amount of solute dissolved in urine - Normal range - 1.002 – 1.035 SPECIFIC GRAVITY - Raised (concentrated urine) in dehydration, SIADH, glycosuria, proteinuria - Decreased (diluted urine) in diabetes insipidus, primary polydipsia PROTEIN - Many causes of proteinuria e.g. UTI, Nephrotic Syndrome, pre -eclampsia, myeloma, glomerulonephritis - Raised in gram-negative urinary tract infections NITRITES - Indicative of white blood cells in urine LEUKOCYTE ESTERASE - Raised in urinary tract infections - Raised in haematuria e.g. Nephritic Syndrome, neoplasms, urinary tract infections, renal calculi, trauma BLOOD - Raised in haemoglobinuria - Raised in myoglobinuria UROBILINOGEN - Raised in haemolytic anaemia & liver damage - Reduced in biliary obstruction - Indicative of conjugated bilirubin BILIRUBIN - Raised in a conjugated hyperbilirubinaemia e.g. biliary obstruction, liver damageAND THA T’S IT! THANKS FOR A GREA T YEAR IT’S BEEN OUR PLEASURE. SEE YOU GUYS NEXT YEAR! @osceazyofficial Osceazy@outlook.com @OSCEazyOfficial OSCEazy