1 / 24

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.

lucie
Download Presentation

Admitting Conference

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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

More Related