As we heard the history we stopped, prior to hearing the exam and labs, and developed a differential diagnosis.  With the combination of itching, probable jaundice and pale stools we assume either intrahepatic or extrahepatic obstruction.  Our differential diagnosis with commentary:

1. Primary biliary cirrhosis – much more common in women then men – but does often present at this age with uncontrollable itching
2. Primary sclerosing cholangitis – no history of ulcerative colitis or diarrhea symptoms, but still possible
3. Gallstone – not all common duct stones cause pain
4. Cholangiocarcinoma – could clearly cause extrahepatic obstruction
5. Pancreatic cancer – probably the number one consideration from history alone.

Physical exam – positive Murphy’s sign

Labs:

CBC and basic metabolic panel unremarkable

Helical CT ordered – will report tomorrow

What is your best guess?  Have we left anything out of the differential?