invite friends ⋅ share via emailtwitter
support the site ⋅ become a member ⋅ unscramble the egg
free120  nbme24  nbme23  nbme22  nbme21  nbme20  nbme19  nbme18  nbme17  nbme16  nbme15  nbme13 
Welcome to morelife’s page.
Contributor score: 0

Comments ...

Subcomments ...

submitted by ashmash(1),
unscramble the site ⋅ become a member ($42/month)

yWh a’cnt we usmaes atht eht ipnttae thwi an leedtave tcderi iiubinrbl odes nto ahev meos srto of ooubnsitrtc herwe eht alaklnie ohpetsphaas wdlou eb etaveedl or( veen ibdun hnojons r?odmse)ny I dtnid’ htnki of eiltrbG eiedsas tepeids hte inmteittrten rceuso abusece I ntde to okol ta etrcid nda attlo inuiiblbr vseell fsrit ot see fi het teidcr iubnbiilr si veleeadt hwcih in isht aesc aws tadve.ele

benwhite_dotcom  Few things. History always comes first. She also has even more indirect bili than direct. There’s also no other indication of obstruction clinically (such as pruritis), and you can’t infer an elevated lab value (alk phos) and rely on that in order to have everything come together. They have to give it to you. +6  
morelife  I saw this question on Gilbert’s and also put down increased ALP. I noticed the relapsing-remitting history. However, my thoughts were that a direct bilirubinemia is a false finding in Gilberts (since it is due to lower UDP enzyme activity), and would more likely indicate obstruction. As you said, you would consciously neglect this finding in favor of the history? For these specific NBME style questions -- you know, the wishy/washy ones -- would you follow the principle of “history first”? +  
benwhite_dotcom  @morelife, Plethora of evidence first. Here everything points in one direction except one small detail. If you were to make a list of pro/cons for each diagnosis using history, physical and objective data (labs, imaging, etc), the scales usually tip firmly in one direction. +1  
wowo  also, unless I'm mistaken, it's not a direct bilirubinemia - tbili is 3 and direct is 1, so unconjugated is 2. They're both elevated. Even with a decrease in function of the enzyme, it still works, so if unconj bili increases, you'll get somewhat of an increase of conjugated bili +  
kindcomet  @wowo, that makes sense if the unconj bili is due to hemolysis but it doesn't make sense if pathophys is literally the conjugation step. I would have expected DECREASED conjugated bili, if anything. +