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

• 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).

History of Present Illness• Gradual enlargement of the

abdomen• No accompanying symptom

• Progressive abdominal enlargement• Consulted at USTH-OPD• Lost to follow up

7 Months PTA

6 Months PTA

History of Present Illness• 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

• Increase in the intensity of pain, now grade 10/10• Increase in the frequency of vomiting• Consulted at USTH ER-CD

22 days PTA

18 days PTA

History of Present Illness18 days PTA

• 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

• Repeat SFA: Mechanical Intestinal Obstruction at the level of the distal megacolon; Ascites

• Started on Spirinolactone 25mg/tab

16 days PTA

• (+) BM, (+) Flatus14 days PTA

History of Present Illness8 days PTA • Paracentesis done:

• PCR for PTB sent to PGH: Negative• Ascitic Fluid Albumin sent to CGH: 1.9g/dL

• Paracentesis done: • obtained 1.3 L of translucent yellowish to

straw colored ascitic fluid

5 days PTA

• Paracentesis done:• obtained 1.2 L of translucent yellowish to

straw colored ascitic fluid

4 days PTA

Transferred

History of Present Illness13 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

• Fast accumulation of Ascites• Paracentesis done:

• Negative Malignant cells• Negative AFB stain

12 days PTA

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

Past Medical History

• (-) allergy• (-) hypertension • (-) diabetes mellitus• (-) thyroid disorder• (-) hepatitis• (-) asthma

Family History

• (+) cancer (prostate) – brother died last 7/13/09

• (+) DM - brother • (+) HPN - mother & brother • (-) thyroid disorder

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

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 erythematous macules 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

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

• Adynamic precordium, AB 5th LICS MCL, S1>S2 apex, S2>S1 base, (-) murmurs

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

Salient Features

Subjective• Abdominal Pain• Abdominal Enlargement• Alcohol intake of 50g/day

for 30 years• (+) anorexia, (+) nausea and

vomiting, (+) bipedal edema grade 2

• (-) fever• (-) bruisability, (-) epistaxis,

(-) melena

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, (-) palmar erythema, (-) gynecomastia, (-) testicular atrophy

Working Diagnosis

• Ascites, probably secondary peritoneal carcinomatosis; r/o alcoholic liver cirrhosis

Diagnostic Plans

• Liver Function Test– AST, ALT– PT, aPTT

• Laparoscopy

Therapeutic Plans

• Therapeutic Paracentesis• Pain reliever

– Tramadol HCl 37.5mg + Paracetamol 325mg/tab (Dolcet) q8h

THANK YOU

LIVER vs PERITONEUM

• SAAG (serum to ascites albumin gradient) – 97%specific

• >1.1 g/dL –portal hypertension related ascites• <1.1g/dL – peritoneal disease

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

Indications for Paracentesis

• Confirm specific Dx:– Amylase, triglyceride, cytology, mycobacterial

smear and culture