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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: ALBERTO, LEONARDO Age/Sex: 50/M Address: 2206 Felixnuertas Sta Cruz, Manila Date of Admission: September 9, 2007 Admitting Diagnosis: Squamous Cell Carcinoma, floor of the mouth Physicians-in-charge: Drs.Chiong/ Luna/ So/ Del Valle/ Tolentino/ Ricardo

Hospital No: 1458516

48 hour history This is a case of a 50 year old male from Sta Cruz, Manila admitted due to a mass on the floor of the mouth. HISTORY OF PRESENT ILLNESS Two and a half years prior to admission, patient noted an aphthous ulcer like lesion on the floor of the mouth, right, associated with occasional pain. He gargled with saline. No consult was done. Six months prior to admission, he noted and increase in size of the mass and presence of cervical lymphadenopathy on the right. Still no consult was sought. One month prior to admission, persistence of the above symptoms and increase in number of nodes prompted consult with a private physician. Patient underwent biopsy which revealed SCCA, moderately differentiated. He was then referred at our institution hence the admission. PAST MEDICAL HISTORY (?) liver disease, (-) HTN, (-) DM, (-) BA, (-) heart disease, (-) thyroid dysfunction, (-) allergy (-) Previous hospitalization FAMILY HISTORY (-) HTN, (-) DM, (-) BA, (-) Ca, (-) heart disease, (-) thyroid dysfunction, (-) allergy PERSONAL/SOCIAL HISTORY Smoker – 27 pack years Alcoholic beverage drinker x 36 years consuming 2-3 bottles of gin per day REVIEW OF SYSTEMS: Constitutional: with 50% weight loss in 6 months, no loss of appetite, no fever HEENT: no headache, no tinnitus, no blurring of vision Respiratiory: no cough, no colds, no dyspnea Cardiovascular: no palpitations, no chest pain, no paroxysmal nocturnal dyspnea, with easy fatigability GIT: no abdominal pain, no change in bowel habits GUT: no dysuria, no oliguria, no hematuria Hematology: no bleeding tendencies, no easy bruisability Neurology: no seizure, no tremors, no motor deficits noted, no sensory loss PHYSICAL EXAMINATION General: conscious, coherent, oriented to three spheres, not in cardiorespiratory distress, afebrile o Vital Signs: BP = 160/80 mmHg CR = 81 bpm RR = 10 cpm T = 36.8 C HEENT: anicteric sclera, pink palpebral conjunctiva

Intact TM (-) abrasion (-) blood clots (-) hyperemia

(-) tragal tenderness (-) deformities

(-) mass (-) septal deviation (-) congestion

Unable to assess

(+) CLAD

(-) TPC; (+) fungating mass Uvula in midline

Unable to assess

Chest/Lungs: Symmetrical chest expansion, no retractions, with spider angiomas, no gynecomastia, clear breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs, no thrills Abdomen: Flat, normoactive bowel sounds, flabby, soft, nontender Extremities: Grossly normal, no edema, no cyanosis, with palmar erythema, full and equal pulses Neuro: with tremors, no neurologic and sensory deficit. ASSESSMENT: Squamous cell carcinoma, floor of the mouth COURSE IN THE WARDS: Patient was admitted to room 216, ENT was under the service of Drs. Chiong/ Luna/ Del Valle/ So/ Ricardo/ Tolentino. Diet was as tolerated. Diagnostics requested were CBC with platelet count, clotting time, bleeding time, blood typing, urinalysis, chest x-ray, and 12-L ECG. Patient was weighed. Vital signs were monitored every 4 hours. Patient was advised to secure 3 units of whole blood and to secure official laboratory results for cardiopulmonary clearance for his operation: COMMANDO with possible reconstruction using pectoralis major flap (minimum of 8 hours operation). On the first hospital day, patient was seen by internal medicine. Additional ancillary procedures were requested, HBTUTZ including the spleen, TB, B1, B2, protime, albumin, PBS, BUN, creatinine, Na, K, SGOT, SGPT, and alkaline phosphatase. He was also referred to the department of Psychiatry regarding alcoholic withdrawal syndrome. Medications given and started were Folic Acid 1 tab BID, Vitamin K 1 tab TID, and lactulose 15cc at bedtime. nd On the 2 hospital day, patient still has tremor. His BP was 160/90, HR 88, and RR of 18. He was in a euthymic mood. He denies suicidal intentions. He was seen and examined by the department of psychiatry, and strict suicide and escape precautions was advised. They also suggested to provide a 24 hour watcher. Their impression was alcohol abuse and dependence, alcoholic withdrawal syndrome. Their plan was to start Propranolol 10mg/tab 1 tab OD and Diazepam 10mg/tab ½ tab at HS. All these were carried out.


				
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