AGRAVANTE CA

							OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD AND NECK SURGERY

NAME: MERARTE A. AGRAVANTE HOSPITAL NO.: 1500459 AGE/SEX: 28/F ADDRESS: Sucat, Paranaque PHYSICIANS IN CHARGE: Drs. So/Del Valle/Ricardo/Tolentino/ Salvador/Vidanes/Catignas/Regino CLERKS IN CHARGE: Fabian/Ilarde/Ingles/Item/Junsay

CLINICAL ABSTRACT History of the Present Illness 1 year PTC, Patient noted to have a mass on the Right anterior neck approximately 1x1 cm, firm, non-movable, non-tender. There were no other associated signs and symptoms during that time. No consult done, no medications taken. 6 months PTC, patient noted the mass to have increase in size, now accompanied with hoarseness of voice. Patient sought consult to a private physician and was given Omapion (unrecalled dose) which brought no relief to her. Few days PTC, there was progression in size of the anterior neck mass with no associated weight loss prompted consult at OMMC ENT-OPD. Past Medical History unremarkable Family History Denies any heredofamilial disease Review of Systems (-) wt loss, (-) anorexia (-) fever (-) eye pain, (-) tinnitus, (-) epistaxis, (-) hoarseness, (-) difficulty swallowing (-) cough, (-) colds, (-) hemoptypsis, (-) chest pain (-) abdominal pain, (-) constipation, (-) changes in bowel habits (-) dysuria, (-) hematuria (-) seizures, (-) convulsions (-) edema PHYSICAL EXAMINATION General Survey Conscious, coherent, NICRD Vital Signs BP = 120/80 HR = 76 RR = 18 Temp = 37.0 EYES: pink palpebral conjunctivae, anicteric sclera, PERTL 2-3 mm CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds HEART: adynamic precordium, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sounds, soft, non-tender EXTREMITIES: grossly normal, full and equal pulses, no cyanosis, no edema ENT Exam

(+) cone of light Intact Tympanic membrane

(-) tragal tenderness (+) residual cerumen

(-) septal deviation (-) congestion

(+) Mass, right 3x2 cm, hard, fixed Anterior, moves with deglutition (-) CLAD

Uvula midline (-) TPC (+) paralysis right vocal cord, paramedian in location Left vocal cord coaptates at midline (-) mass AD No lateralization AC>BC Equal + AS No lateralization AC>BC Equal +

TUNING FORK EXAM WEBER RINNE SCHWABACH BING

ASSESSMENT:

t/c THYROID MALIGNANCY VOCAL CORD PARALYSIS, RIGHT for TOTAL LOBECTOMY RIGHT with ISTHMUSECTOMY & NEAR TOTAL LOBECTOMY LEFT

PLAN: