ABSTRACT
An 89-year-old woman was referred to hospital by her general practitioner (GP) with jaundice. She was unclear when the jaundice had initially developed, but her son had first noticed it 2 weeks earlier and reported that the jaundice was progressing. Around 1 month earlier, she had been admitted to hospital with progressive shortness of breath and had been investigated for a presumed community-acquired pneumonia. A chest x-ray showed atelectasis at the right base plus a deviated trachea. A computed tomography (CT) scan of the chest, abdomen and pelvis (to investigate for possible malignancy) identified fibrotic changes at the right lung base but no other abnormalities. During the admission, the patient was noted to have developed deranged liver function with a marked transaminitis (bilirubin 8 μmol/L, ALT 245 IU/L, ALP 60 IU/L), which was attributed to a recent course of co-amoxiclav. She was discharged home after 2 days with a plan for her GP to review her in the community. Since then, the patient had remained dyspnoeic. She denied a cough or fever and there was no postural component to her dyspnoea. She complained of weight loss, although she was unable to quantify this further, as well as generalised lethargy and malaise. She denied pruritus and had no abdominal pain or change in bowel habit. Her stools were described as brown in colour, but she thought that her urine may be darker than it usually was. Her past medical history included hypertension, hypercholesterolaemia and recurrent urinary tract infections. She took regular 2.5 mg ramipril OD, 30 mg lansoprazole OD and 25 mg atenolol OD. She lived alone and had never smoked. She did not regularly drink alcohol and she had not travelled abroad in the preceding year. She was a retired script-writer who lived alone at home without assistance.
