Office visit on 3/15--  he admits to being fatigued otherwise he feels well and has no complaints  DIAGNOSIS: #1.  Right upper quadrant abdominal pain #2.  Hydrops gallbladder on CT scan 3.  Liver mass by CT scan CT shows: IMPRESSION:  1.  Poorly marginated right hepatic lobe mass measuring approximately 7 x 4 x 4.4 cm in size. Metastatic disease should be considered.  2.  Upper abdominal adenopathy with mildly prominent phrenic and retrocrural lymph nodes.  3.  Cholelithiasis with hydropic gallbladder and trace pericholecystic fluid. Please correlate.  4.  No discrete common duct calculi identified.  5.  Small right renal cysts.  6.  Mildly distended bladder.  7.  Basilar lung scarring with small granuloma  # Metastatic cholangiocarcinoma with lung metastases We reviewed his PET/CT and pathology results from his recent liver biopsy in clinic today which confirms metastatic cholangiocarcinoma. We discussed that metastatic disease is not considered curable although treatable and reviewed life expectancies for metastatic cholangiocarcinoma with and without anti-neoplastic therapy. We discussed chemotherapy options including, Gemcitabine/Cisplatin vs 5-FU/Oxaliplatin vs Gemcitabine/Capecitabine. We also discussed the risks, benefits and potential toxicities of each regimen. He does have tinnitus at baseline which we discussed may worsen with Cisplatin. We also discussed the risk for worsening of his peripheral neuropathy, secondary to his diabetes, if treatment with Oxaliplatin is pursued. After consideration of the toxicity profiles of each regimen, he favored starting treatment with Gemcitabine and Cisplatin. We discussed that I would have a low threshold to change treatment if he develops worsening of his baseline symptoms. We discussed that treatment with Gemcitabine and Cisplatin is given two weeks in a row followed by a week off. We will plan to send the tissue from the liver biopsy for NGS testing in the meantime to assess for genetic mutations which may offer alternative treatment options. We discussed that radiation therapy would not be recommended in the metastatic setting unless symptomatic from disease. We will place a referral to IR for port placement, however will place a picc line for the first cycle of treatment if a port cannot be placed prior. He would like to receive treatment as often as possible   ED 6/21/21:  Patient arrives for increased headaches and coordination unbalance related to a fall and hitting head this weekend.  He fel backwards hitting his head backwards on Saturday.  Had first chemo treatment on prior Friday before the fall.  No vomiting but headache is different then his usual migraines and since was unsure of step a and fell two more times.  No change in speech but did have two episodes of hallucinations or illusions of things that were not true on Sunday and resolved today.  9/15/21  Acute deep vein thrombosis (DVT) of right lower extremity, unspecified vein (HCC)  DVT/PE TREATMENT ONLY: rivaroxaban (XARELTO) 15 & 20 MG therapy starter pack   HYDROmorphone (DILAUDID) 2 mg tablet 2. Portal vein thrombosis    3. Diabetic peripheral neuropathy (HCC)  HYDROmorphone (DILAUDID) 2 mg tablet    4. Right upper quadrant pain    9/27/21 ED abdominal pain, hypomagnesemia, positive D dimer, yponatermia, dehydration, elevated bilirubin, history of DVT, thrombosis, lactic acid acidosis.  9/29/21 lactic acidosis, cirrhosis of liver, weakness, dehydration, hypomagnesemia, altered mental status, elevated CRP, hyponatremia