Yongphumphuttha,Yuwadee

GENERAL DATA
• Q.M
• 55 y.o/female
• Filipino
• Married
• Roman Catholic
• Cordova,Cebu City
• Admitted for the first time in CHH
 Chief complaint
• Jaundice
 Past Medical History
• Hypertensive for 10 years on maintenance
medication Metoprolol(Neobloc) 100mg OD
• Diabetic (no maintenance medication)
• Nonasthmatic
• No food and drug allergies
• Admitted in 2017 in District hospital due to
Hypokalemia
 Family history
• Hypertension on both paternal and maternal
side
• No family history of cancer
 History of present illness
• 3 weeks PTA, noted onset of hypogastric pain
,non radiating. No medications taken.
Condition tolerated.
• 1 week PTA, noted onset of icteric sclerae with
persistence of symptoms. Still no consult ws
done.
• 4 days PTA, noted persistence of symptoms
now asssociated with generalized body
weakness
 History of Present Illness
• 1 day PTA, sought consult with AP and was
advised for Ultrasound with whole abdomen .
Showed gallstones and was advised to seek
consult with Dr.Bullo for further
manangement.
• Hours PTA, patient sought consult with
dr.Bullo and was requested for CT scan with
contrast whole abdomen thus this admission.
 Personal and social habits
• Nonsmoker
• Nonalcoholic
 Physical Eaxmination
Seen and examined patient awake, responsive,
afebrile not in respiratory distress, with the
following vital signs:
T: 37.1c BP:100/70 mmHg
P: 57 bpm 02 sat: 95%
R: 20 cpm Wt 69.10
Ht 157.5
BMI 27.86 (overweight)
 Physical Examination
• Skin : Jaundice, good turgor and mobility
• HEENT : equal palpebral fissures, icteric
sclerae, pale conjunctivae, symmetric ears, no
deformities, (-) nasoaural discharge , nasal
septum at midline, dry lips, no oral lesions, no
tonsillopharyngeal tonsils,
• Neck : supple , trachea in midline , no
lymphadenopathy
Chest and Lungs: symmetric chest, equal chest
expansion, equal tactile fremitus, clear breath
sound
CVS: Distinct S1 and S2, regular rate and rhythm,
no murmurs

ABD: soft, nontender , nonpalpable mass

( -) Grey turner’s sign (-) Cullen’s sign
GUT: (-) KPS
EXT: symmetrical, no deformities, no edema, strong
peripheral pulses, CRT <2 secs, no limitation of
movement on both upper and lower extremities
RECTAL EXAM: N/A

Neurologic Exam: Within normal limits, GCS 14

Test Result references
Urea Nitrogen 14.1 7.0-18.0
Creatinine 1.5 0.5-1.5
SGPT 739 5.0-50.0
Alkaline Phosphatase 194 45.0-125.0
Total Bilirubin 24.2 0.0-1.0
Direct Bilirubin 17.0 0.0-0.3
Indirect Bilirubin 7.2 00.0-0.7

Test Result References

Albumin 1.7 3.5-5.0
Globulin 5.1 2.5-3.4
Sodium 137 134-148
Potassium 2.7 3.3-5.3
HBSAG
HBsAG (qualitative) Nonreactive

Test result
Alpha-Feto Protein(Liver,Germ 58.8 <7.0
cell tumors)
CA 19-9 (Pancreas, G I T) 139.6 0-37
 Admitting impression
• T/C Cholangiocarcinoma
 Plan
• Cefuroxime 750 mg IVTT q 8 hr
• CT scan whole abdomen with contrast on
Monday
 Cholangiocarcinoma
• Rare tumor arising from biliary epithelium and
may occur anywhere along biliary tree
• 2/3 are located at hepatic duct bifurcation
• Male to female 1.3 : 1
• Common to most risk factors include biliary
stasis, bile duct stones , and infection
• 95 % of bile duct cancers are adenocarcinoma
• Devided into distal ,proximal , or perihilar
tumors
• 2/3 are located perihilar location
• Referred to as Klatsin tumors classigied based
on anatomic location by the Bismuth-Corlette
classification
Type

I Tumors are confined to common hepatic

duct

II Involve the bifurcation without

involvement of secondary intrahepatic
ducts

IIIa Tumor extend to right hepatic duct

IIIb Tumor extend to left hepatic duct

IV Tumors involve both the right and left
secondary intrhepatic ducts
• Post hepatic causes of jaundice are usually the
result of intrinsic or extrinsic obstruction of
the biliary duct system that prevents the flow
of bile into duodenum
• Intrinsic obstruction can occur from biliary
diseases , including cholelithiasis,
choledocholithiasis, benign and malignant
biliary strictures, cholangiocarcinoma
• For primary liver cancers or hepatic metastasis
, Hepatic resection is the gold standard and
treatment of choice