A 54 year old women was admitted with shortness of breath wich had gradually become worse over last month. she had been a heavy smoker all her life and admitted that her tendency to drink to excess led to her divorce five year earlier. She had had a life-long history of migraine and had taken a multitude of headache remedies over many years from different GPs. During the year preceding her admission she felt increasingly listless and had lost 7 kg in weight. she had also complained of back pain in the lumber region which was made worse after drinking fluids.



on examination she was an ill looking pigmented women with pale mucous membranes, leuconychia and erythema ab igne over the lumber spine . Her pluse war regular at 80 per minute, blood pressure 115/60mmHg and respiratory rate 30 per minute. There were no other abnormalities in CVS or respiratory system and physical examination of other system was normal. The urine contained + protien but no glucose, and was normal on microscopy