1. GS III SGD January 28, 2012 Block 10A

2. Patient Profile EC, 49/M from Cavite Married with 2 kids, works as a carpenter Chief complaint: Jaundice

3. History of Present Illness 1 month PTA, Pt started experiencing acute onset RUQ pain, VAS 5/10, worsened by activity and eating. (-) nausea, vomiting, fever, jaundice. RUQ pain persisted, no consult done, until… 4 days PTA, persistence of pain and onset of jaundice with tea-colored urine prompted consult at a local Cavite hospital. (-) n/v, fever. UTZ done, A > choledocholithiasis

4. History of Present Illness HBT UTZ done (Jan 3, 2012): non-visualized gallbladder, could be due to perihepatic/hepatic infection, physiologic contraction, sludge vs stone-filled lumen and small gb; choledoectasia 2 to DBD calculus or mass lesion, pressure effect 2 to inflamed pancreas; prominent hypoechoic pancreas, consider pancreatitis Persistence of sx prompted consult at PGH.

5. Review of Systems (-) fever (-) headache (-) acholic stools (-) bowel movt changes (-) pruritus (-) DOB, chest pain, palpitations (-) melena, hematochezia

6. Past Medical History (-) HPN, BA, DM, allergies (-) Hep B (-) previous surgeries/hospitalizations

7. Personal & Social History Works as a carpenter (-) alcohol, smoking, illicit drug use

8. Physical Examination Alert, awake, coherent, NICRD 130/80902036.3 Anicteric sclerae, pink conjunctivae (-)anterior neck mass, CLAD Equal chest expansion, clear breath sounds Adynamic precordium, distinct heart sounds, normal rate & regular rhythm, (-) murmurs

9. Physical Examination Soft & flabby abdomen, normoactive bowel sounds (+) guarding, (+) RUQ tenderness on light palpation, (-) palpable masses Full & equal pulses, pink nailbeds, (-) cyanosis/clubbing/edema

10. Admitting Impression Obstructive Jaundice 2 to choledocholithiasis, t/c biliary pancreatitis

11. Diagnostics WBC 6.10RBC 4.31 Hgb 134Hct 0.380 MCV 88.1MCH 31.0 MCHC 352RDW 15.4 Plt 268 Neut 0.609Lymph 0.257 Mono 0.107Eos 0.025 Baso 0.001

12. Diagnostics BUN 5.10Crea 79 Alk phos 516TB 222.4 DB 124.8IB 97.6 Amylase 51Lipase 103 Na 136K 3.6 Cl 103

13. Diagnostics Urinalysis: yellow orange, slightly cloudy pH 5.5sp gr 1.043 Trace blood(+++) bilirubin (+) urobilinogen(-) ketones, nitrites, leuk, aa Trace albumin(+++) glucose FBS 14.68

14. Diagnostics PT 16.2/0.87/1.18 PTT 30.6/28.8 Albumin 25 CA 19-9 30.43

15. Diagnostics Upper GI Endoscopy: scope inserted up to D2 with difficulty, (+) extrinsic mass at D1, normal stomach, normal LES, normal esophagus. A > t/c pancreatic CA HBT UTZ:

16. Plan For EL with intraoperative ultrasound

17. Findings at Operation Pt underwent EL with intraoperative UTZ on January 25, 2012: Periampullary Ca St IV with liver metastasis