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 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

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 Relieved by food intake? Rest/ 18 days PTA Increase in the intensity of pain, now grade 10/10 Increase in the frequency of vomiting Consulted at USTH ER-CD

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

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

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

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 Objective Abdominal Pain Abdominal Enlargement Alcohol intake of 50g/day for 30 years (+) anorexia, (+) nausea and vomiting, (+) bipedal edema grade 2 (-) fever (-) bruisability, (-) epistaxis, (-) melena 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