General Surgeon HPB Consultation Note

**CHIEF COMPLAINT:** 1. Severe right upper quadrant abdominal pain, radiating to the back. 2. Yellowing of the skin and eyes. 3. Dark urine and pale stools. **HPI TODAY:** 01/11/2024 Mrs. Eleanor Vance, a 68-year-old female, presents with a 3-week history of worsening right upper quadrant abdominal pain, which she describes as "a constant, dull ache that sometimes feels like a sharp stab." The pain is non-radiating but occasionally feels like it goes through to her back. She also reports a 1-week history of progressive jaundice, dark urine, and pale, clay-coloured stools. She denies fever, chills, nausea, vomiting, or significant weight loss. She states, "I've lost my appetite a bit, but I haven't been trying to lose weight." She has no history of gallstones or previous pancreatitis. **I personally reviewed and interpreted the scans and agree with the findings.** CT Abdomen/Pelvis performed on 28/10/2024 at St. Jude's Hospital: Revealed a 2.5 cm mass in the head of the pancreas, causing dilation of the common bile duct and intrahepatic ducts. No obvious distant metastases were identified. The lesion appears resectable. MRI Cholangiopancreatography (MRCP) performed on 30/10/2024 at Regional Imaging Centre: Confirmed the pancreatic head mass and severe common bile duct obstruction. No evidence of vascular involvement of the superior mesenteric artery or portal vein was noted, suggesting potential resectability. Serum Bilirubin (total) on 30/10/2024: 125 umol/L (elevated). Liver Function Tests (LFTs) on 30/10/2024: ALP 350 U/L, GGT 400 U/L (both significantly elevated), AST 60 U/L, ALT 70 U/L (mildly elevated). CA 19-9 on 30/10/2024: 1500 U/mL (markedly elevated). Mrs. Vance is a retired primary school teacher and enjoys gardening and reading. She notes that her current symptoms have significantly impacted her ability to participate in these hobbies. PMH, PSH, MEDS, ALLERGIES, SH, and FH: - Information reviewed with patient and in EMR, with changes made where appropriate. - PMH: Hypertension, well-controlled on medication; Type 2 Diabetes, diet-controlled. No prior surgeries. No known drug allergies. Social History: Non-smoker, rarely consumes alcohol. Family History: Mother passed away from colon cancer at age 75. Father died of a myocardial infarction. PHYSICAL EXAMINATION: CONSTITUTIONAL: Well-developed, well-nourished female in mild discomfort but not acute distress. Jaundiced sclera and skin noted. Alert and oriented to person, place, and time. PSYCHIATRIC: Mood is anxious but cooperative. Affect is appropriate to the situation. Judgement and thought content appear intact. ABDOMINAL EXAMINATION: Soft, non-distended. Moderate tenderness to palpation in the right upper quadrant. No guarding or rebound tenderness. Positive Murphy's sign absent. No palpable masses or organomegaly. Bowel sounds are normoactive. **ASSESSMENT AND PLAN:** Mrs. Vance is a 68-year-old female presenting with obstructive jaundice and right upper quadrant pain, highly suspicious for a resectable pancreatic head mass based on imaging and tumour markers. 1. Pancreatic Head Mass, likely adenocarcinoma with obstructive jaundice. - ASSESSMENT: High clinical suspicion for pancreatic adenocarcinoma given patient's age, symptoms, imaging findings (mass in pancreatic head causing bile duct dilation, no clear vascular involvement, no distant mets), and elevated CA 19-9. Patient is currently jaundiced and symptomatic. - PLAN: Proceed with endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) for tissue diagnosis and potential biliary stenting to relieve obstruction. "I just want to know what it is so we can do something," she stated. Will also order a repeat CT chest for further metastatic workup. Discuss case at multidisciplinary team (MDT) meeting for formal staging and management planning. Pending MDT discussion, surgical exploration for pancreaticoduodenectomy (Whipple procedure) is a strong consideration given current findings. - COUNSELLING: Discussed the likely diagnosis of pancreatic cancer, its aggressive nature, and the importance of multidisciplinary management. Explained the rationale for EUS/FNA for diagnosis and stenting for jaundice relief. Discussed the Whipple procedure as the potential definitive treatment, outlining its complexity and potential risks, including fistula, bleeding, and infection. Patient understood the need for further tests and the proposed surgical approach. **ORDERS:** - EUS with FNA of pancreatic head mass and biliary stenting for obstruction. - Repeat CT Chest. - Continue current home medications. - NPO after midnight for EUS procedure. **FOLLOW UP:** Follow-up appointment to be scheduled in 1 week following EUS results and MDT discussion to review findings and finalise management plan. Patient will be contacted by the nurse coordinator regarding EUS scheduling. **SHORT SUMMARY:** Mrs. Vance, a 68-year-old, presents with obstructive jaundice and RUQ pain, indicative of a pancreatic head mass. Imaging and tumour markers are highly suggestive of pancreatic adenocarcinoma. The plan involves EUS with FNA and biliary stenting, further staging, and discussion at MDT, with potential for a Whipple procedure.