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| Physical Exam | 06/02/XX |
69 year old male with increased liver enzymes. Recent ultrasound, CT of gallbladder at outside facility showed gallstones. On exam neck supple, chest clear. Abdomen soft and nontender without adenopathy. |
| X-Rays & Scans | 05/27/XX |
CXR negative for malignancy. |
| Scopes | 05/27/XX |
ERCP attempted, blocked by apparent gallstone. |
| 06/30/XX | Diagnostic laparoscopy w/cholecystectomy and intraoperative cholangiogram. Excisional biopsy of peritoneal masses x 2. | |
| Pathological Reports | 06/30/XX |
Cholecystectomy: 2.5 cm moderately differentiated adenocarcinoma invades through muscle wall into adjacent adipose tissue. Lymphatic space invasion present. Invasive carcinoma and high grade dysplasia present at apparent cystic duct margin and within < 1.0 mm of cauterized hepatic margin. Peritoneal biopsy: poorly differentiated adenocarcinoma compatible with gallbladder lesion. |
| Treatment | 06/30/XX |
Laparoscopic cholecystectomy. |
| 08/01/XX | Started chemo: Gemzar. | |
