CPC: Case Study

History of Present Illness:
The patient is a pleasant 73-year-old male who presented with jaundice, pruritis, and malaise of approximately two weeks. He has had a 23 lb. weight loss over the past month. The patient was seen by his local primary care physician who noted abnormal liver function tests: Albumin 3.1, Total Bilirubin 7.3, Direct Bilirubin 5.8, SGOT 131, SGPT 319, Alk Phos 488, GGTP 1135, Ferritin 615, PT 10.9 seconds. Hepatitis serologies were negative. His CEA was 3.1, CA19-9 was 1972, and AFP was 6.1. An abdominal sonogram revealed no ductal dilatation, and a 2cm cyst was noted in the right lobe of the liver. A CT scan of the abdomen revealed intrahepatic and extrahepatic bile duct dilatation, without focal masses. The patient was referred to a local gastroenterologist. The gastroenterologist performed an ERCP, which showed a bile duct stricture, and a biliary endoprosthesis was placed (See Image 1). The patient was referred to The Johns Hopkins Hospital for additional work-up.

Social History
Patient is a retired traffic signal engineer, who then opened up a fiberglass business. He is married with two daughters. His wife has early Alzheimer's disease. He has a remote smoking history and drinks socially (one highball per day). He lives in Florida and Memphis, Tennessee.

Allergies
Questionable allergy to dye.

Medications
Norvasc (amlodipine besylate), Flomax (tamsulosin hydrochloride), and Prilosec (omeprazole).

Review of Systems
Patient denies headaches, change in vision, changes in hearing, chest pain or palpitations, cough or shortness of breath, dysuria or hematuria, joint pain or skin rashes, change in bowel habits, nausea, constipation, or diarrhea.

Physical Exam
The patient is a healthy appearing gentleman who appears his stated age and is no acute distress. Vital Signs: BP=120/80, P=60, RR=16. He is not cachectic. Face is symmetrical. His pupils are equal, round, and react to light and accommodation. Extra-ocular movements are intact. Sclerae are anicteric. Conjunctivae are pink. He does not have cervical or supraclavicular lymphadenopathy. His clinical exam reveals a normal S1 and S2 with a regular rate and rhythm. His lungs are bilaterally clear to auscultation without wheezing or rhochi. His abdomen is not distended and he does not demonstrate hepatosplenomegaly or peri-umbilical adenopathy. He has a long right subcostal healed incision. Extremities show no clubbing, cyanosis, or edema. Neurologically, cranial nerves 2 through 12 are grossly intact, with movement in all four extremities.

Radiology:
Chest x-ray is unremarkable, negative for metastatic disease.
A multidetector 3D CT scan shows a small cystic lesion in the pancreatic tail associated with pancreatic ductal dilatation in the body and tail (See Image 2). The cystic lesion measures approximately one centimeter. A discrete pancreatic mass is not seen. A biliary endoprosthesis is present. No bile duct dilatation is present.

Image 2

Questions to consider: