•Temperature 36.7°C, pulse 66 bpm, BP 100/53mmHg, SaO₂ 98-100% on RA.

•Alert, no jaundice, no stigmata of chronic liver disease.

•Examination of the hands reveals no clubbing and normal-appearing palmar creases.

•Head and neck examination is unremarkable, with no lymph nodes palpable.

•Cardiovascular: HS dual, no murmur.

•Her chest is clear on auscultation.

•Abdominal examination reveals a soft, non-tender abdomen, with no organomegaly.

•No signs of oedema.

Investigations

•CBC is normal.

•Bilirubin 12μmol/L.

•ALP 1375 IU/L (incidental finding).

•ALT 115 IU/L (incidental finding).

•Renal function is normal.

What is your differential diagnosis?

•Biliary obstruction.

•Hepatocellular disease, e.g. cirrhosis, alcoholic liver disease.

•Drug-induced cholestasis.

•Hepatocellular carcinoma.

•Infiltrative disease, e.g. tuberculosis, sarcoidosis.

•Primary biliary cirrhosis (PBC).

•Primary sclerosing cholangitis (PSC).

What further history would you enquire?

•Drinking history.

•Drug history including herbs and over-the-counter medications.

What further blood tests would you order for the work-up of the underlying aetiology of deranged liver function?

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