The man, in his 60s, had enjoyed good health until 6 weeks ago.  His symptoms started with modest itching, but over the past 2 weeks it had become unbearable.  During this time, he had lost 20 pounds because he had both nausea and some post-prandial vomiting.  A physician had tried hydroxyzine, without any symptom relief.  He denied abdominal pain.  He had never had similar symptoms.  He was taking no new medications.

Over the past week relatives and friends told him that he was starting to look yellow.

On further questioning he told us that he had dark urine but chalky colored stools.

Part 1 – develop a differential diagnosis and ask for testing – we can provide answers tomorrow