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Patient Medical Report

Complete patient history, investigations, treatment and specialist opinions
Generated: 2026-09-25 06:03 Patient Record: 6
Full Name
عبدالرحمن المناصير
Identification Number
9521012872
Age
74
Gender
Male
Telephone Number
00000000
Record Created
2026-07-27 08:58
Last Updated
-

History of Present Illness (HPI)

74Y M K/C OF CHOLANGIOCARCINOMA WITH METS REFERRED TO US DUE TO RECURRENT VISITS TO ER DUE TO ABD PAIN VOMITING WEIGHT LOSS >20 KG IN LAST 4 MONTHS SUSPICIOUS CHOLANGIOCARCINOMA WITH METS ON PET SCAN IN : LNS IN NECK, ABD, CHEST, LUNGS AND BONE.

Medical Conditions

1 record(s)
Condition Type Diagnosis Date ICD-10 Severity Status Notes
COPD Chronic - J44.9 - In Remission -

Family Medical History

0 record(s)
No family medical history was recorded.

Social History

Marital Status
Married
Employment Status
Unknown
Occupation
Unknown
Living Arrangement
Unknown
Tobacco Use Status
Current
Tobacco Type
Cigarettes
Cigarettes per Day
-
Smoking Start Age
-
Smoking Quit Age
-
Pack-Years
-
Passive Smoke Exposure
Current
Alcohol Use
Unknown
Alcohol Details
-
Recreational Drug Use
Unknown
Drug Details
-
Physical Activity
Low
Diet Description
Low fat diet
Occupational Exposures
-
Environmental Exposures
-
Social Support
Family
Additional Notes
-

Surgeries

4 record(s)
PTC INSERTION
2026-07-23
Findings
Anterograde cholangiogram shows severe left intrahepatic biliary dilation with occluded segment of left biliary duct. 8.5 FR internal-external biliary drain was inserted and functioning well.
PTC INSERTION
2026-07-21
Findings
Anterograde cholangiogram shows severe left intrahepatic biliary dilation with occluded segment of left biliary duct. 8 FR external biliary drain was inserted and functioning well.
RT ORCHIDECTOMY
2006-07-27
Findings
SPECIFIC DATE AND FINDINGS UNKNOWN
Appendectomy
2001-07-27
Findings
SPECIFIC DATE AND FINDINGS UNKNOWN

Chemotherapy

0 record(s)
No chemotherapy records were recorded.

Radiology Records

3 record(s)
Histopathology - Supraclavicular Lymph Node Biopsy
2026-07-27
Status
Pending
Attached Files
0
Facility
-
Radiologist
-
Clinical Indication
Staging
Findings
Pending
Impression
Pending
Notes
-
PET Scan - Whole Body
2026-05-31
Status
Completed
Attached Files
0
Facility
-
Radiologist
-
Clinical Indication
Suspected Cholangiocarcinoma
Findings
-
Impression
Hypermetabolic potentially malignant liver lesion, mostly originating from the biliary tree and highly suspicious cholangiocarcinoma, tissue confirmation is mandatory. Hypermetabolic potentially metastatic process involving multiple lymph nodes groups within neck, chest and abd, both lungs and bone.
Notes
-
MRI - MRI ABDOMEN (LIVER KIDNEY, PANCREAS) (MRCP)
2026-05-05
Status
Completed
Attached Files
0
Facility
-
Radiologist
-
Clinical Indication
-
Findings
-
Impression
The constellation of findings are mostly consistent with cholangiocarcinoma with lung and bony metastases.
Notes
-

Specialist Opinions

1 record(s)
Medical Oncology
2026-08-03
Specialist Name
-
Opinion Note
Palliative chemotherapy
Recommendation
Palliative chemotherapy Cisplatin Gemzar

Laboratory Tests

4 record(s)
Date Test Category Result Reference Range Status Notes
2026-04-29 CA19-9 Tumor Markers 21.59 U/ml 0-39 Normal -
2026-04-29 CA 125 Tumor Markers 131.5 U/ml 0-35 High -
2026-04-29 CEA Tumor Markers 55.43 Ng/ml Up to 5.0 (smoker) High -
2026-04-29 AFP Tumor Markers 7.6 Ng/ml Up to 10.0 (SMOKER) High -