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Admitting Conference

Admitting Conference. 217 – E Clerk YUMUL, ARVIN R. General Data. ACM 53/M/Married Tondo , Manila Roman Catholic Date of Admission : January 31, 2010 Informant : Patient and sister Reliability : 80 % . Chief Complaint. Abdominal Enlargement. History of Present Illness.

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Admitting Conference

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  1. Admitting Conference 217 – E Clerk YUMUL, ARVIN R.

  2. General Data • ACM • 53/M/Married • Tondo, Manila • Roman Catholic • Date of Admission: January 31, 2010 • Informant: Patient and sister • Reliability: 80%

  3. Chief Complaint • Abdominal Enlargement

  4. History of Present Illness • Patient was diagnosed to have Moderately differentiated Squamous Cell Carcinoma of the Larynx stage III (T3N0Mx); s/p ‘E’ tracheostomy and biopsy (8/25/08); s/p total laryngectomy and selective neck dissection, left (9/18/08). s/p radiotherapy 30 cycles at USTH-BCI (2/5/09 to 4/7/09).

  5. History of Present Illness • 7 Months PTA • Gradual enlargement of the abdomen • No accompanying symptom • 6 Months PTA • Progressive abdominal enlargement • Consulted at USTH-OPD • Lost to follow up

  6. History of Present Illness • 22 days PTA • Persistent progression of the abdominal enlargement • Developed generalized abdominal pain • “kumikirot”, graded 7/10, continuous, non-radiating • Nausea • Vomiting of previously ingested food: 3 episodes about 15mL each • (+) early satiety, (+) anorexia • No bowel movement, no flatus • 18 days PTA • Increase in the intensity of pain, now grade 10/10 • Increase in the frequency of vomiting • Consulted at USTH ER-CD

  7. History of Present Illness • Assessed to have Intestinal Obstruction • SFA – small bowel obstruction • Admitted under General Surgery • CBC w/ plt, Na, K, Crea, FBS, CXR, 12-lead ECG and TPAG were requested • Low albumin 3.7g/dL • CXR: consider PTB both upper lobes; Pleural effusion, bilateral but more on the right • (+) bipedal edema • 18 days PTA • 16 days PTA • Repeat SFA: Mechanical Intestinal Obstruction at the level of the distal megacolon; Ascites • Started on Spirinolactone 25mg/tab • 14 days PTA • (+) BM, (+) Flatus

  8. History of Present Illness • 8 days PTA • Paracentesis done: • PCR for PTB sent to PGH: Negative • Ascitic Fluid Albumin sent to CGH: 1.9g/dL • 5 days PTA • Paracentesis done: • obtained 1.3 L of translucent yellowish to straw colored ascitic fluid • 4 days PTA • Paracentesis done: • obtained 1.2 L of translucent yellowish to straw colored ascitic fluid • Transferred

  9. History of Present Illness • 13 days PTA • CT scan of the whole abdomen with triple contrast showed: • Massive Ascites • Collapsed and displaced descending, ascending, sigmoid colon • No mass • No lymphadenopathies • Pleural effusion bilateral but more on the right • 12 days PTA • Fast accumulation of Ascites • Paracentesis done: • Negative Malignant cells • Negative AFB stain

  10. Review of Systems • (+) undocumented weight loss • No easy fatigability, no weakness • No blurring of vision • No ear pain, itchiness, aural discharges or hearing loss • No sore throat • No neck stiffness, no limitation of motion • No dyspnea, no shortness of breath, no cough, no wheezing • No chest pain, no orthopnea, no PND, • No hypertension • No dysuria, no urgency, no hesitancy, no flank pain • No joint stiffness, pain or swelling • No palpitations, no tremors, no polyuria, no polydipsia, no polyphagia • No heat or cold intolerance • No dizziness, no seizures, no headaches • No easy bruisability, prolonged bleeding • No anxiety, no depression

  11. Past Medical History • (-) allergy • (-) hypertension • (-) diabetes mellitus • (-) thyroid disorder • (-) hepatitis • (-) asthma

  12. Family History • (+) cancer (prostate) – brother died last 7/13/09 • (+) DM - brother • (+) HPN - mother & brother • (-) thyroid disorder

  13. Personal and Social History • Mixed diet – usually composed of meat, fish, vegetables and fruits, but with poor appetite • Ensure 6-8 glasses/day • Heavy smoker – 1 ½ packs/ day for 30 years (45 pack-years), stopped 2 years ago • Alcoholic beverage drinker for 30 years: 1 beer grande/day (1000mL) = 50g/day

  14. Physical Examination • Vital Signs • BP: 110/80 mmHg; PR:90 bpm; RR 30 cpm; Temp:36.5°C • Conscious, coherent, wheelchair borne, not in cardiorespiratory distress • Warm moist skin, (+) multiple erythematousmacules on both lower aspect of lower legs • Pink palpebral conjunctivae, anicteric sclera, pupils 2-3 mm ERTL • No tragal tenderness, non-hyperemic EAC, intact tympanic membrane, no aural discharge; Midline septum, no nasal discharge, non-congested and non-hyperemic turbinates

  15. Physical Examination • Dry cracked lips, moist buccal mucosa, non-hyperemic PPW, tonsils not enlarged • Supple neck, no palpable cervical lymphadenopathies, tracheostomy tube in place • Symmetrical chest expansion, no retractions, dull on percussion on the lower lobes of both lungs, decreased breath sounds on the lower lobe of both lungs, clear breath sounds • Adynamicprecordium, AB 5th LICS MCL, S1>S2 apex, S2>S1 base, (-) murmurs

  16. Physical Examination • Globularly enlarged, firm abdomen, (+) venous collaterals, (+) shifting dullness, (+) fluid wave, hypertympanitic on percussion, generalized tenderness, normoactive bowel sounds • No cyanosis, (+) bipedal edema grade 2 • Pulses full and equal

  17. Salient Features Subjective Objective 53 y/o male Diagnosed with SCC of the Larynx stage III, (T3N0Mx) Globularly enlarged, firm abdomen, (+) venous collaterals, (+) shifting dullness, (+) fluid wave, hypertympanitic on percussion, generalized tenderness, normoactive bowel sounds RR = 30cpm Dull on percussion on the lower lobes of both lungs, decreased breath sounds on the lower lobe of both lungs (-) spider angioma, (-) palmarerythema, (-) gynecomastia, (-) testicular atrophy • Abdominal Pain • Abdominal Enlargement • Alcohol intake of 50g/day for 30 years • (+) anorexia, (+) nausea and vomiting, (+) bipedal edema grade 2 • (-) fever • (-) bruisability, (-) epistaxis, (-) melena

  18. Working Diagnosis • Ascites, probably secondary peritoneal carcinomatosis; r/o alcoholic liver cirrhosis

  19. Diagnostic Plans • Liver Function Test • AST, ALT • PT, aPTT • Laparoscopy

  20. Therapeutic Plans • Therapeutic Paracentesis • Pain reliever • Tramadol HCl 37.5mg + Paracetamol 325mg/tab (Dolcet) q8h

  21. THANK YOU

  22. LIVER vs PERITONEUM • SAAG (serum to ascites albumin gradient) • 97%specific • >1.1 g/dL –portal hypertension related ascites • <1.1g/dL – peritoneal disease

  23. Indications for Paracentesis • Diagnosis – esp. when suspicious of malignancy or SBP • Therapeutic – significant discomfort or respiratory compromise • Routine exam includes: • Cell count and diff count • TP, Albumin • Culture

  24. Indications for Paracentesis • Confirm specific Dx: • Amylase, triglyceride, cytology, mycobacterial smear and culture

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