Instructions
You are a medical student on placement in general practice. Lorena Galli, 54, a lawyer, saw the GP last week with a year of itching all over and tiredness. The GP has asked you to review her results before she comes back in.
Interpret the results provided
Outline to the examiner:
- Your findings
- Your most likely diagnosis and differentials
- You do not need to take a history or examine the patient
- Ms Galli is in the waiting room; you will speak to the examiner
- The examiner will ask you questions at the end
GP notes, last week
Itch all over for about 12 months, worse at night in bed; no rash. Tired by mid-afternoon most days; still working full time. Gritty, dry eyes for two years. No jaundice, dark urine, pale stools, abdominal pain, fever or weight loss.
Family and social
Mother has an underactive thyroid. Two standard drinks a week; never smoked.
Medicines
Carmellose eye drops when needed; loratadine 10 mg daily for 3 months, with no effect on the itch. No other medicines, herbal remedies or supplements, and nothing new in the past year.
GP examination, last week
Scratch marks on the forearms, shins and upper back. Not jaundiced. Small, flat yellow plaques at the inner corners of both upper eyelids. No spider naevi or palmar erythema. Abdomen soft and non-tender; liver and spleen not palpable.
Full blood count and liver tests (GP, last week)
Hb 134 g/L (115-165); WCC 6.2 (4.0-11.0); platelets 238 (150-400). Bilirubin 14 umol/L (under 20); ALP 380 U/L (30-110); GGT 290 U/L (5-35); ALT 52 U/L (under 35); AST 45 U/L (under 35); albumin 40 g/L (35-50); INR 1.0 (0.9-1.2)
Lipids and thyroid (GP, last week)
Total cholesterol 7.2 mmol/L (under 5.5); HDL cholesterol 2.1 mmol/L (high; over 1.0 is desirable); TSH 1.8 mIU/L (0.4-4.0)
Liver screen (GP, last week)
Antimitochondrial antibody (M2): positive, titre 1:640 (normal: negative). Antinuclear antibody: negative. Smooth muscle antibody: negative. IgM 4.6 g/L (0.4-2.3); IgG 12.8 g/L (7.0-16.0). Hepatitis B surface antigen and hepatitis C antibody: not detected.
Bloods (GP, last week)
| Item | Value | Reference range |
|---|---|---|
| Haemoglobin | 134 g/L | 115-165 g/L |
| White cell count | 6.2 x10^9/L | 4.0-11.0 x10^9/L |
| Platelets | 238 x10^9/L | 150-400 x10^9/L |
| Bilirubin (total) | 14 umol/L | <20 umol/L |
| ALP | 380 U/L | 30-110 U/L |
| GGT | 290 U/L | 5-35 U/L |
| ALT | 52 U/L | <35 U/L |
| AST | 45 U/L | <35 U/L |
| Albumin | 40 g/L | 35-50 g/L |
| INR | 1.0 | 0.9-1.2 |
| Total cholesterol | 7.2 mmol/L | <5.5 mmol/L |
| HDL cholesterol | 2.1 mmol/L | >1.0 mmol/L (desirable) |
| TSH | 1.8 mIU/L | 0.4-4.0 mIU/L |
Liver screen (GP, last week)
| Item | Value | Reference range |
|---|---|---|
| Antimitochondrial antibody (M2) | Positive, titre 1:640 | Negative |
| Antinuclear antibody | Negative | Negative |
| Smooth muscle antibody | Negative | Negative |
| IgM | 4.6 g/L | 0.4-2.3 g/L |
| IgG | 12.8 g/L | 7.0-16.0 g/L |
| Hepatitis B surface antigen | Not detected | Not detected |
| Hepatitis C antibody | Not detected | Not detected |