Oncology Ward Progress Notes

April --, 2023

E.C || 58/F
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HPI:
2 weeks PTA, patient experienced abdominal pain on LLQ, sharp 8/10, more prominent during the night.
Patient also noted her abdomen to increase in girth. Patient took Omeprazole 40mg/cap and Celecoxib 200
mg/tab twice a day which offered partial relief. There was an associated early satiety, with nausea but no
episodes of vomiting. No other associated symptoms such as fever or LBM. Patient sought consult due to an
increase in girth of the abdomen and increase in severity of abdominal pain, hence admission.

SUBJECTIVE s/p Colonoscopy (04/06/2024)

s/p Paracentesis -2.5L (03/24/2024)
s/p Peritoneal drain insertion (04/01/2024)

Currently,
With abdominal pain and feelings of bloatedness
With early satiety
No chest pain, no DOB
No desaturations
OBJECTIVE Vital Signs
BP: 100/70, HR: 88, RR: 19, Temp: 36.7, SpO2: 97% at room air

Awake, conscious, coherent

No pallor, no jaundice
Anicteric sclera, pink palpebral conjunctiva
(+) midline neck mass (21cm x 9cm), irregular, firm, nontender
SCWE, CBS, no wheezes/crackles/rhonchi
AP, NRRR, no murmurs
Abdomen is flabby, distended, tympanitic on all quadrants
(+) peritoneal catheter on LLQ, (+) intact inflated colostomy bag on RLQ
FEPP, CRT <2s, No BPE
ASSESSMENT Ascites probably secondary to carcinomatosis; Splenic flexure mass probably
malignant s/p trephine ileostomy (2/2/2023, BGHMC); Hyperthyroidism secondary to
multinodular non-toxic goiter; Anemia probably secondary to chronic disease; Acute
kidney injury pre-renal secondary to poor oral intake; Colitis of Disuse; Luminal
Obstruction from Compression of the Mass
PLAN Diagnostics:
WAB Chest CT scan scheduling

Therapeutics:
1. Celecoxib 200 mg/tab 1 tab BID prn for pain
2. Metoclopramide 10mg IV q8 hours PRN for nausea/vomiting
3. Propranolol 40mg 2 tabs bid
4. Salbutamol + ipratropium neb q12 hours PRN for dyspnea
 5. Methimazole 5 tabs TID

Advised to:
- Continue daily drainage of peritoneal fluid
- BP precautions
- I and O monitoring

PJBG .
Junior Intern