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
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

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 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

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
Adynamic precordium, 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 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

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