Department of surgery clinical abstract



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OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF SURGERY
CLINICAL ABSTRACT






Name: Zoleta, Dolores Hospital #: 2063080

Address: Sunny Brook, San Francisco, Cavite CIty Age/Sex: 62/F

Date of Admission: November 3, 2009

Admitting Diagnosis: SCCA, floor of the mouth

Surgeons in charge: Drs. Deveza/Balucating/Sunaz/Peralta/Ilarde

Intern-in-charge: PGI Navarro

Clerk-in-Charge: JI Victa

This is a case of a 62 year old female who came in due to mandibular mass.


History of Present Illness

6 months prior to consult, a painful, erythematous swelling was noted by the ptient at her right submandibular area. Along with this, a submental mass was also noted. Patient approximated the mass to be less than 1cm x 1cm in size and without any discharge. This prompted the patient to consult at St. Jude’s Hospital. At the said institution, panoramic x-ray and incision biopsy were done. The result of panoramic x-ray revealed edentulous maxilla and mandible while the result of excision biopsy revealed undifferentiated carcinoma that may either be ameloblastic carcinoma or odontogenic origin. Patient was advised to undergo surgery but refused due to financial constraints.

3 months prior to consult, there was persistence of above symptoms with an increase in the size of the mass. This prompted another consult at the Manila Adventist Medical Center. She was prescribed with Mefenamic Acid 500mg/cap PRN for pain and he was reportedly compliant with the said medication. However, only partial relief was provided by the said medication. He had several other follow-ups at the said institution but was eventually advised to seek consult at our institution hence consult.
Past Medical History

(-) BA


(-) DM

(-) PTB


No previous hospitalizations

No known allergies to food and drugs



Family History

(-) BA


(-) DM

(-) HPN


(-) Cancer

Personal and Social History

Npnsmoker

Non-alcoholic beverage drinker

Review of Systems


General: no fever, no weight loss and no loss of appetite

Eyes: No eye pain, no itching, no redness, no excessive tearing (lacrimation), no double vision.

Ears: no pain and no discharge

Nose: No stuffiness and no nasal discharge, no bleeding of the nose, pain, nasal obstruction, and loss of smell.

Mouth and Throat: No mouth sores and no loss of sense of taste. No sore throat and no difficulty in swallowing. No hoarseness and no coarseness of voice.

Respiratory: No DOB, no dyspnea, no cough, no colds

Cardiovascular: No history of chest pain, no history of cyanosis and no palpitation.

Gastrointestinal: no change in bowel movement, no melena, no hematochezia

Genito-urinary: without frequency, no dysuria, no gross hematuria, no incontinence

Endocrine: no heat or cold intolerance, no polydipsia, no polyphagia

Nerological: No history of transient disorientation and memory loss and no history of seizure attacks. no weakness, no joint pain, no muscle pain, no stiffness, no tremors

Physical Examination

General Survey: Patient is conscious, coherent, NICRD

Vital Signs: BP: 120/70 CR: 72 RR: 20 T: 36.6oC

HEENT: (+) mass, 2x2cm, soft, nontender and movable on the left mandible with purulent discharge. anicteric sclerae, pale palpebral conjunctivae, (-) nasoaural discharge, no tonsilo-pharyngeal congestion

CHEST AND LUNGS: symmetrical chest expansion, (-) retractions, clear breath sounds

HEART: adynamic precordium, normal rate and regular rhythm, no murmur

ABDOMEN: flabby, normoactive bowel sounds, soft, (+) direct tenderness and rebound tenderness at right lower quadrant

EXTREMITIES: grossly normal, full and equal pulses
Assessment

SCCA floor of the mouth



Plan

For admission.








OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF SURGERY
24 HOUR HISTORY






Name: Zoleta, Dolores Hospital #: 2063080

Address: Sunny Brook, San Francisco, Cavite CIty Age/Sex: 62/F

Date of Admission: November 3, 2009

Admitting Diagnosis: SCCA, floor of the mouth

Surgeons in charge: Drs. Deveza/Balucating/Sunaz/Peralta/Ilarde

Intern-in-charge: PGI Navarro

Clerk-in-Charge: JI Victa

This is a case of a 62 year old female who came in due to mandibular mass.


History of Present Illness

6 months prior to consult, a painful, erythematous swelling was noted by the ptient at her right submandibular area. Along with this, a submental mass was also noted. Patient approximated the mass to be less than 1cm x 1cm in size and without any discharge. This prompted the patient to consult at St. Jude’s Hospital. At the said institution, panoramic x-ray and incision biopsy were done. The result of panoramic x-ray revealed edentulous maxilla and mandible while the result of excision biopsy revealed undifferentiated carcinoma that may either be ameloblastic carcinoma or odontogenic origin. Patient was advised to undergo surgery but refused due to financial constraints.

3 months prior to consult, there was persistence of above symptoms with an increase in the size of the mass. This prompted another consult at the Manila Adventist Medical Center. She was prescribed with Mefenamic Acid 500mg/cap PRN for pain and he was reportedly compliant with the said medication. However, only partial relief was provided by the said medication. He had several other follow-ups at the said institution but was eventually advised to seek consult at our institution hence consult.
Past Medical History

(-) BA


(-) DM

(-) PTB


No previous hospitalizations

No known allergies to food and drugs



Family History

(-) BA


(-) DM

(-) HPN


(-) Cancer

Personal and Social History

Npnsmoker

Non-alcoholic beverage drinker

Review of Systems


General: no fever, no weight loss and no loss of appetite

Eyes: No eye pain, no itching, no redness, no excessive tearing (lacrimation), no double vision.

Ears: no pain and no discharge

Nose: No stuffiness and no nasal discharge, no bleeding of the nose, pain, nasal obstruction, and loss of smell.

Mouth and Throat: No mouth sores and no loss of sense of taste. No sore throat and no difficulty in swallowing. No hoarseness and no coarseness of voice.

Respiratory: No DOB, no dyspnea, no cough, no colds

Cardiovascular: No history of chest pain, no history of cyanosis and no palpitation.

Gastrointestinal: no change in bowel movement, no melena, no hematochezia

Genito-urinary: without frequency, no dysuria, no gross hematuria, no incontinence

Endocrine: no heat or cold intolerance, no polydipsia, no polyphagia

Nerological: No history of transient disorientation and memory loss and no history of seizure attacks. no weakness, no joint pain, no muscle pain, no stiffness, no tremors

Physical Examination

General Survey: Patient is conscious, coherent, NICRD

Vital Signs: BP: 120/70 CR: 72 RR: 20 T: 36.6oC

HEENT: (+) mass, 2x2cm, soft, nontender and movable on the left mandible with purulent discharge. anicteric sclerae, pale palpebral conjunctivae, (-) nasoaural discharge, no tonsilo-pharyngeal congestion

CHEST AND LUNGS: symmetrical chest expansion, (-) retractions, clear breath sounds

HEART: adynamic precordium, normal rate and regular rhythm, no murmur

ABDOMEN: flabby, normoactive bowel sounds, soft, (+) direct tenderness and rebound tenderness at right lower quadrant

EXTREMITIES: grossly normal, full and equal pulses
Assessment

SCCA floor of the mouth



Plan

For admission. Patient was admitted under the service of Drs. Deveza/Balucating/SUnaz/Peralta/Ilarde. Consent for admission and management was secured. Patient was placed on DAT. Laboratories requested were the following: CBC with PC, CXR-PA, 12LECG and serum Na, K, BUN, crea and FBS. Patient was booked to OR for commando. The following medications were given: CIproflixacin 500mg/tab, 1 tab BID PO and Mefenamic Acid 500mg/tab, 1 tab TID PRN for pain with meals.









OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF SURGERY
48 HOUR HISTORY






Name: Zoleta, Dolores Hospital #: 2063080

Address: Sunny Brook, San Francisco, Cavite CIty Age/Sex: 62/F

Date of Admission: November 3, 2009

Admitting Diagnosis: SCCA, floor of the mouth

Surgeons in charge: Drs. Deveza/Balucating/Sunaz/Peralta/Ilarde

Intern-in-charge: PGI Navarro

Clerk-in-Charge: JI Victa

This is a case of a 62 year old female who came in due to mandibular mass.


History of Present Illness

6 months prior to consult, a painful, erythematous swelling was noted by the ptient at her right submandibular area. Along with this, a submental mass was also noted. Patient approximated the mass to be less than 1cm x 1cm in size and without any discharge. This prompted the patient to consult at St. Jude’s Hospital. At the said institution, panoramic x-ray and incision biopsy were done. The result of panoramic x-ray revealed edentulous maxilla and mandible while the result of excision biopsy revealed undifferentiated carcinoma that may either be ameloblastic carcinoma or odontogenic origin. Patient was advised to undergo surgery but refused due to financial constraints.

3 months prior to consult, there was persistence of above symptoms with an increase in the size of the mass. This prompted another consult at the Manila Adventist Medical Center. She was prescribed with Mefenamic Acid 500mg/cap PRN for pain and he was reportedly compliant with the said medication. However, only partial relief was provided by the said medication. He had several other follow-ups at the said institution but was eventually advised to seek consult at our institution hence consult.
Past Medical History

(-) BA


(-) DM

(-) PTB


No previous hospitalizations

No known allergies to food and drugs



Family History

(-) BA


(-) DM

(-) HPN


(-) Cancer

Personal and Social History

Npnsmoker

Non-alcoholic beverage drinker

Review of Systems


General: no fever, no weight loss and no loss of appetite

Eyes: No eye pain, no itching, no redness, no excessive tearing (lacrimation), no double vision.

Ears: no pain and no discharge

Nose: No stuffiness and no nasal discharge, no bleeding of the nose, pain, nasal obstruction, and loss of smell.

Mouth and Throat: No mouth sores and no loss of sense of taste. No sore throat and no difficulty in swallowing. No hoarseness and no coarseness of voice.

Respiratory: No DOB, no dyspnea, no cough, no colds

Cardiovascular: No history of chest pain, no history of cyanosis and no palpitation.

Gastrointestinal: no change in bowel movement, no melena, no hematochezia

Genito-urinary: without frequency, no dysuria, no gross hematuria, no incontinence

Endocrine: no heat or cold intolerance, no polydipsia, no polyphagia

Nerological: No history of transient disorientation and memory loss and no history of seizure attacks. no weakness, no joint pain, no muscle pain, no stiffness, no tremors

Physical Examination

General Survey: Patient is conscious, coherent, NICRD

Vital Signs: BP: 120/70 CR: 72 RR: 20 T: 36.6oC

HEENT: (+) mass, 2x2cm, soft, nontender and movable on the left mandible with purulent discharge. anicteric sclerae, pale palpebral conjunctivae, (-) nasoaural discharge, no tonsilo-pharyngeal congestion

CHEST AND LUNGS: symmetrical chest expansion, (-) retractions, clear breath sounds

HEART: adynamic precordium, normal rate and regular rhythm, no murmur

ABDOMEN: flabby, normoactive bowel sounds, soft, (+) direct tenderness and rebound tenderness at right lower quadrant

EXTREMITIES: grossly normal, full and equal pulses
Assessment

SCCA floor of the mouth



Plan

For admission. Patient was admitted under the service of Drs. Deveza/Balucating/SUnaz/Peralta/Ilarde. Consent for admission and management was secured. Patient was placed on DAT. Laboratories requested were the following: CBC with PC, CXR-PA, 12LECG and serum Na, K, BUN, crea and FBS. Patient was booked to OR for commando. The following medications were given: CIproflixacin 500mg/tab, 1 tab BID PO and Mefenamic Acid 500mg/tab, 1 tab TID PRN for pain with meals.


On the 2nd hospital day, patient was seen by anesthesia department. Surgical airway prior to OR under MAC was suggested. NPO 8 hours prior to OR was was also suggested to be done once patient is scheduled for surgical operation. IVF to be started once scheduled for OR: D5LR and another line of PNSS. Patient was ordered to secure units of of whole bllod properly typed and crossmatched for possible OR use. The department also requested for blood typing and for the patient to be referred to Internal Medicine Department for CP clearance.







OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF SURGERY
PATIENT DISCHARGE SUMMARY






Name: Zoleta, Dolores Hospital #: 2063080

Address: Sunny Brook, San Francisco, Cavite CIty Age/Sex: 62/F

Date of Admission: November 3, 2009

Admitting Diagnosis: SCCA, floor of the mouth

Surgeons in charge: Drs. Deveza/Balucating/Sunaz/Peralta/Ilarde

Intern-in-charge: PGI Navarro

Clerk-in-Charge: JI Victa

This is a case of a 62 year old female who came in due to mandibular mass.


History of Present Illness

6 months prior to consult, a painful, erythematous swelling was noted by the ptient at her right submandibular area. Along with this, a submental mass was also noted. Patient approximated the mass to be less than 1cm x 1cm in size and without any discharge. This prompted the patient to consult at St. Jude’s Hospital. At the said institution, panoramic x-ray and incision biopsy were done. The result of panoramic x-ray revealed edentulous maxilla and mandible while the result of excision biopsy revealed undifferentiated carcinoma that may either be ameloblastic carcinoma or odontogenic origin. Patient was advised to undergo surgery but refused due to financial constraints.

3 months prior to consult, there was persistence of above symptoms with an increase in the size of the mass. This prompted another consult at the Manila Adventist Medical Center. She was prescribed with Mefenamic Acid 500mg/cap PRN for pain and he was reportedly compliant with the said medication. However, only partial relief was provided by the said medication. He had several other follow-ups at the said institution but was eventually advised to seek consult at our institution hence consult.
Past Medical History

(-) BA


(-) DM

(-) PTB


No previous hospitalizations

No known allergies to food and drugs



Family History

(-) BA


(-) DM

(-) HPN


(-) Cancer

Personal and Social History

Npnsmoker

Non-alcoholic beverage drinker

Review of Systems


General: no fever, no weight loss and no loss of appetite

Eyes: No eye pain, no itching, no redness, no excessive tearing (lacrimation), no double vision.

Ears: no pain and no discharge

Nose: No stuffiness and no nasal discharge, no bleeding of the nose, pain, nasal obstruction, and loss of smell.

Mouth and Throat: No mouth sores and no loss of sense of taste. No sore throat and no difficulty in swallowing. No hoarseness and no coarseness of voice.

Respiratory: No DOB, no dyspnea, no cough, no colds

Cardiovascular: No history of chest pain, no history of cyanosis and no palpitation.

Gastrointestinal: no change in bowel movement, no melena, no hematochezia

Genito-urinary: without frequency, no dysuria, no gross hematuria, no incontinence

Endocrine: no heat or cold intolerance, no polydipsia, no polyphagia

Nerological: No history of transient disorientation and memory loss and no history of seizure attacks. no weakness, no joint pain, no muscle pain, no stiffness, no tremors

Physical Examination

General Survey: Patient is conscious, coherent, NICRD

Vital Signs: BP: 120/70 CR: 72 RR: 20 T: 36.6oC

HEENT: (+) mass, 2x2cm, soft, nontender and movable on the left mandible with purulent discharge. anicteric sclerae, pale palpebral conjunctivae, (-) nasoaural discharge, no tonsilo-pharyngeal congestion

CHEST AND LUNGS: symmetrical chest expansion, (-) retractions, clear breath sounds

HEART: adynamic precordium, normal rate and regular rhythm, no murmur

ABDOMEN: flabby, normoactive bowel sounds, soft, (+) direct tenderness and rebound tenderness at right lower quadrant

EXTREMITIES: grossly normal, full and equal pulses
Assessment

SCCA floor of the mouth



Plan

For admission. Patient was admitted under the service of Drs. Deveza/Balucating/SUnaz/Peralta/Ilarde. Consent for admission and management was secured. Patient was placed on DAT. Laboratories requested were the following: CBC with PC, CXR-PA, 12LECG and serum Na, K, BUN, crea and FBS. Patient was booked to OR for commando. The following medications were given: CIproflixacin 500mg/tab, 1 tab BID PO and Mefenamic Acid 500mg/tab, 1 tab TID PRN for pain with meals.


On the 2nd hospital day, patient was seen by anesthesia department. Surgical airway prior to OR under MAC was suggested. NPO 8 hours prior to OR was was also suggested to be done once patient is scheduled for surgical operation. IVF to be started once scheduled for OR: D5LR and another line of PNSS. Patient was ordered to secure units of of whole bllod properly typed and crossmatched for possible OR use. The department also requested for blood typing and for the patient to be referred to Internal Medicine Department for CP clearance. Patient was still allowed to have diet as tolerated with strict aspiration precaution. The following labs were requested: 2D echo, lipid profile, and blood ABGs. Bloodtyping results were followed up later during the day. Final CP clearance shall be carried out once lab results are complete.
On the 3rd hospital day, present diet was continued. Patient was for 2D echo and trip ticket for the ambulance use was facilitated. Once in, the 2D echo results must be referred back immediately to IM for final CP clearance.

On the 4th hospital day, 2D echo result was followed up. Present management was continued.





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