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“ Ang Hirap Huminga !” A PATIENT IN RESPIRATORY DISTRESS

“ Ang Hirap Huminga !” A PATIENT IN RESPIRATORY DISTRESS. Matthew S.Parco MD-MBA 080080 Ateneo de Manila University St. Martin de Porres Charity Hospital. Patient Information. Name: R.D.P. Age: 35 years old Sex: Female Civil Status: Married

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“ Ang Hirap Huminga !” A PATIENT IN RESPIRATORY DISTRESS

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  1. “AngHirapHuminga!”A PATIENT IN RESPIRATORY DISTRESS Matthew S.Parco MD-MBA 080080 Ateneo de Manila University St. Martin de Porres Charity Hospital

  2. Patient Information Name: R.D.P. Age: 35 years old Sex: Female Civil Status: Married Birthdate: Born on 04 Nov 1976 (Batangas) Address: Bo-ot, Tanauan, Batangas Educational Attainment: High School Graduate

  3. Chief Complaint Abdominal Pain

  4. History of Present Illness • 1 month PTA • Sudden abdominal pain • Hypogastric area • Crampy, radiating to the back. • Accompanied by: • Small, hard stools • Vomiting during eating. • Diagnosed in a local hospital as Muscle Strain • Unrecalled analgesics. • Minimal relief.

  5. History of Present Illness • 2 weeks PTA, • Hypogastric mass noted. • UTZ done: Multiple masses • CTS done: Multiple mass in ovary and retroperitoneum.

  6. History of Present Illness • 1 day PTA, persistence of symptoms • (+) Dyspnea • Admission

  7. Past Medical History • Bronchial Asthma • Last attack: March 23, 2012 (2 days PTA) • Medication: Ventolinpro re nata • Hypertension • Usual BP 120/80 • Highest BP 150/100 • Allergies • Eggs • Tagalognamanok(Native chicken)

  8. Obstetrics and Gynecology History • Menstrual History • Menarche: 12 years of age • Interval and Duration: 28-30 days; 3 days • Amount: 3 pads per day, fully soaked • LMP: 03/08/2012 • Obstetric History • G3P3 (3003) • 1998: NSD, full term, girl, home • 2007: NSD, full term, girl, hospital • 2008: CS 1, eclampsia, girl, Mercado hospital • Family Planning Methods: Withdrawal

  9. Family History (+) Hypertension - maternal

  10. Personal and Social History No preference for any diet. Does not smoke. Does not drink alcoholic beverages. Does not use illicit drugs.

  11. Review of Systems *General.Weight loss of 25% Musculoskeletal and Dermatologic. Rashes present. No lumps, sores, itching, muscle pains, joint pains, changes in color, joint swelling, changes in hair/nails, and gout. Head, Eyes, Ears, Nose, Throat.Frequent coughs and colds. No history of head injury. No headache, dizziness, blurring of vision, tinnitus, deafness, epistaxis, hoarseness, dry mouth, or gum bleeding. Respiratory. No hemoptysis or cough. Cardiovascular. No palpitations, chest pains, syncope, and orthopnea. Gastrointestinal. Appetite good; no vomiting, dysphagia, indigestion, or food allergies; No jaundice. (+) Constipation, (+) Abdominal Pain, (+) Bleeding in stools. Genitourinary. No nocturia, dysuria, urinary frequency, and hematuria. Endocrine. No known thyroid trouble or history of diabetes. No recent change in weight.

  12. Physical Examination • Vitals • Blood Pressure 130/50 • Temperature 36.5 • Pulse rate 108 • Respiratory rate 28 • General Survey • Conscious and coherent, in respiratory distress • Skin • Macular rashes on both lower extremities. No jaundice. No flushing.

  13. Physical Examination • Head and Neck • Anicteric sclera with pink palpebral conjunctiva • No tonsillopharyngeal congestion. • Thyroid not enlarged. • Supraclavicularlymphadenopathies notes on the left neck. • Breasts • Symmetric, with no masses or lesions. • Cardiovascular • Irregular rate and regular rhythm. • Adynamicprecordium, with no heaves, thrills, or murmurs.

  14. Physical Examination • Thorax/Lungs • Equal chest expansion. • Breath sounds with wheezes. • Abdomen • Flat abdomen with generalized tenderness. • (+) Palpable mass on right pelvic area. • Hyperactive bowel sounds. • Rectal Exam • No lesions, masses, or skin tags. • Intact sphincter tone. • (+) Fecal matter and (-) Gross blood on tactating finger.

  15. Physical Examination • Musculoskeletal • No tenderness, swelling, or limitation of motion in any joint. • Neurological • GCS 15 • Cranial Nerves are intact. • Motor 5/5 • Sensory 100% • Reflexes 2+ (superficial, deep tendon, abnormal) • No involuntary movements.

  16. Initial Impression • Pleural Effusion, right • Probably Malignant

  17. Initial Impression • Uterine mass • Probably Malignant.

  18. Plan Emergency Closed Tube Thoracostomy, right.

  19. Malignant Pleural Effusion • A pleural effusion is an accumulation of an abnormal amount of fluid between the visceral and parietal pleura of the chest. • Common complication of malignancy. • 40% of all symptomatic Pleural Effusions traceable from Malignancy. • Lung cancer and Breast cancer account for 50-65% of all Pleural Effusions. • Lymphoma and Leukemia account for 10% of all Pleural Effusions.

  20. Pathogenesis • Normal pleural fluid space: 10 cc of fluid with 2 g/dL protein. • Fluid absorbed by pulmonary venous capillaries (80-90%). • Malignant effusions usually exudativethan transudative (Light’s Criteria): • Pleural fluid : Serum protein ratio > 0.5 • Pleural fluid : Serum lactate dehydrogenase ratio > 0.6 • Pleural fluid LDH > 2/3 of the upper limit of serum LDH

  21. Pathogenesis • Causes of exudative malignant effusions: • Pleural metastases • Disruption of pulmonary capillary endothelium • Malignant obstruction of pleural lymphatics. • Paramalignant effusions from: • Chemotherapy • Radiation therapy • Atelectasis • Lymph Node Involvement.

  22. Pathogenesis • Primary Organ Neoplasm Site: • Male • Lung (49.1%) • Lymphoma or leukemia (21.1%) • Gastrointestinal (7.0%) • Female • Breast (37.4%) • Genitourinary Tract (20.3%) • Lung (15.0%)

  23. Signs and Symptoms • Common symptoms of Malignant Pleural Effusion • Dyspnea • Cough 75% of all patients. • Chest discomfort • Weight Loss and Malaise: 20% of all patients. • Depending on performance status, expected survival, and preference for risks versus benefits

  24. Work-Up • Radiography • Chest Radiography • 175 cc  Blunt costophrenic angle. • Chest Computerized Tomography • Loculated effusions (especially behind the diaphragm). • Chest Ultrasound (Chian, et.al., 2004; Quereshi, et.al., 2009) • Sensitivity of 73% and Specificity of 100% • Distinguish malignant pleural effusions from non-malignant: • Visible pleural metastases • Pleural thickening > 1cm. • Pleural nodularity. • Diaphragmatic thickening measuring > 7 mm. • Echogeic swirling pattern visible in pleural fluid.

  25. Work-Up • Pleural Fluid Cytology (Positive in 60%) • Minimum of 250 cc. • Sensitivity of 65%, Specificity of 97% • Cancer patients can also develop congestive heart failure, pneumonia, pulmonary embolism, malnutrition, and hypoalbuminemia. • Pleural biopsy • CT guided biopsy: Sensitivity of 87% (Maskell, Gleeson, Davies, 2003). • Flow cytometry • Especially for lymphoma • Thoracoscopy • Yield of 80%

  26. Management • Pleural effusions are generally markers of advanced, unresectable disease. • Median survival is around 3 to 4 months (Burrows, et.al., 2000; Sahn, 2001); 3 to 11 months (Schwartz, 2010). • Goal of therapy is symptom palliation. • Complete drainage of the effusion. • Lung re-expansion. • Lack of fluid reaccumulation (i.e., duration of response). • Subjective report of symptom relief. • The choice of treatment depends on patient prognosis, functional status, and goals of care.

  27. Management • Thoracentesis • Percutaneous insertion of needle for drainage of effusion. • Alleviates symptoms in 96% of patients (spontaneous pleurodesis in 44%). • Reaccumulation of effusions usually occur (98% by day 30). • Repeated thoracentesis carry risks of bleeding, infection, and pneumothorax. • Pulmonary edema from rapid lung re-expansion (>1500 cc) • Pleural shock from vagal response to penetration of pleura.

  28. Management • Pleurodesis • Creation of inflammation and subsequent fusion of parietal and visceral pleura. • Meta-analysis of pleurodesis studies from 1966 to 1992 (Walker-Renard, 1994): • 2/3 of all patients respond to pleurodesis. • Tetracycline, bleomycin, and talc are the most effective agents. • Cohort study of urokinase in patients with loculations (Hsu, Soong, Feng, 2006): • 60% of patients reported resolution of dyspnea. • Maintenance of pleurodesis when urokinase followed by minocyline.

  29. Management • Chest Tube Insertion (Thoracostomy) • Insertion of chest tube into pleural cavity to drain air, blood, bile, pus, or other fluids. • Contraindications include need for thoracotomy, coagulopathy, pulmonary bullae, pulmonary or pleural adhesions, loculated pleural effusions, or skin infection over chest tube insertion site. • This allows for continuous, large volume drainage.

  30. Management Chest Tube Insertion

  31. Management Treatment algorithm for Malignant Pleural Effusion

  32. Ovarian Cancer • Symptoms include bloating, pelvic pain, difficulty eating, frequent urination. • Ninety percent are epithelial, rising from the surface of the ovary. • Increased risk in older women and those who have first or second degree relatives. • P53: 96% of ovarian adenocarcinoma patients • BRCA1, BRCA2: 5-13% of ovarian cancers (lifetime risk of 60-85% for carriers). • Infertile women • Endometriosis • Hormonal replacement therapy.

  33. Ovarian Cancer • Protective factors • Early age at first pregnancy and older age of final pregnancy • Use of low dose hormonal contraception (decreases risk by 50%). • Tubal ligation (reduce risk by 72% in women with BRCA1 gene). • Diagnosis • Physical examination • Blood test (CA-125) • Transvaginal ultrasound

  34. Ovarian Cancer • Staging • Stage 1: Limited to one or both ovaries. • Stage 2: Pelvic extension or implants. • Stage 3: Peritoneal implants outside of the pelvis. • Stage : Distant metastases to the liver or outside the peritoneum. • Prognosis • More than 60% of women with presenting signs and symptoms of Ovarian Cancer have Stage III or IV cancer. • Five year survival rate for all stages is 47%. • Second most common gynecologist cancer and deadliest.

  35. THE END

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