Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
I. History of Present Illness
Onset and duration of symptoms:
Jaundice (yellowing of skin and sclerae)
Pruritus (itching)
Abdominal pain (location, severity)
Dark urine
Light-colored stools
Fatigue
Weight loss
Prior episodes of cholangitis (inflammation of bile ducts)
Risk factors for cholangiocarcinoma (Klatskin tumor):
Primary sclerosing cholangitis (PSC)
Inflammatory bowel disease (ulcerative colitis, Crohn’s disease)
Thorotrast contrast exposure
Familial history of cholangiocarcinoma
II. Past Medical History
Significant medical conditions
Allergies (medications)
Surgical history (prior abdominal surgeries)
III. Social History
Alcohol use
Tobacco use
IV. Physical Exam
General: Appearance of illness, jaundice, scleral icterus (yellowing of sclerae)
Skin: Icteric skin, exanthems (skin rashes) suggestive of cholangitis
Abdomen: Palpable liver mass, palpable gallbladder (if present)
Lymph nodes: Enlarged lymph nodes (suggestive of advanced disease)
V. Laboratory
Liver function tests:
Elevated bilirubin (conjugated and unconjugated)
Elevated alkaline phosphatase (ALP)
Elevated gamma-glutamyl transferase (GGT)
Other:
Complete blood count (CBC) – may show anemia
Electrolytes
Coagulation studies (PT, PTT)
VI. Imaging
Ultrasound of the liver and biliary system: Initial imaging modality to assess for bile duct obstruction and potential liver masses.
Magnetic resonance cholangiopancreatography (MRCP): Detailed imaging of the bile ducts and pancreas to delineate the location and extent of the tumor.
CT scan with contrast (if MRCP contraindicated): May be used instead of MRCP to visualize the biliary system and surrounding structures.
ERCP (endoscopic retrograde cholangiopancreatography) (if indicated): May be used for therapeutic purposes (stent placement for bile duct drainage) or for tissue sampling if suspicion for malignancy is high.
VII. Assessment
Klatskin tumor (suspected or confirmed) based on clinical presentation, imaging findings, and potential tissue biopsy results (if available).
Tumor stage (based on imaging and other factors) – TNM staging system is used for cholangiocarcinoma.
Presence of obstructive jaundice and need for biliary drainage.
VIII. Plan
Definitive diagnosis: Consider tissue biopsy (percutaneous needle biopsy or during ERCP) if not already performed for confirmation of malignancy.
Management: Depends on tumor stage, resectability, and patient’s overall health. Options include:
Surgical resection: Curative approach for early-stage tumors.
Biliary stenting: To relieve biliary obstruction and improve jaundice symptoms.
Chemotherapy: May be used alone or in combination with radiation therapy for advanced or unresectable tumors.
Radiation therapy: May be used in combination with chemotherapy for some patients.
Palliative care: To manage symptoms and improve quality of life for advanced or unresectable tumors.
Consultation: Consider consultation with a surgical oncologist, hepatobiliary surgeon, or medical oncologist for definitive management plan based on individual circumstances.
Supportive care: Management of pruritus, malnutrition, and other associated symptoms.
Follow-up:
Schedule follow-up appointments to monitor response to treatment, assess for complications, and adjust plan as needed.
Imaging follow-up with CT scan or MRCP may be needed to monitor tumor response.