2. Basic data Name: OO Age: 47y/o Gender: Male Admission: 6.17/2014 Education: Junior high school Occupation: Chart number: 41840334
3. Chief complaint Hemoptysis for 2 days
4. Present illness This 47 y/o male with history of liver cirrhosis and HBV infection was admitted to our ER due to hemoptysis for 2 days. As the statement of him, he has followed up his liver disease in our OPD. But he lost followed up since 2011.
5. Half a year ago, he would have been choked sometimes while drinking water. Bleeding after taking food and dysphagia were mentioned, too. About 2 weeks ago, a left submandibular mass was noted by him. Also, he complained about tarry stool.
6. Present illness nausea(-) vomiting (-) dizziness (-) nosebleed(-) dyspnea(-) chest tightness(-) fever(-) cold sweating(-) abdominal pain(-) cough(-) dysuria(-) anti-coagulant use (-) He suffered from hemoptysis since 2 days ago. Therefore, he went to our ER.
7. Past medical history Hospitalization: 2010.3.3 -3.15 2011.5.6 -5.14 2011.8.27 -9.5 GI bleeding -> Esophageal Varices s/p EVL
8. Personal history Allergy: none Alcohol: heavy drinkiner() Betal nut: yes Cigarette: 0.5ppd for 20 years Travel history: denied Family history: Father had DM type II
9. Physical examination GCS: E4M6V5 T/P/R: 37.7/104/25 BP: 101/68 HEENT Eyes-Conjunctiva: pale -Corneayellow Neck-Generalleft neck big mass
10. Physical examination -Carotid pulsesregular , normal amplitude, no bruits. -Jugular veinno engorgement Chest and Lungs -Inspectionnormal thoracic cage, normal expansion, no spider nevi. -Palpationequal tactile fremitus. -Percussionresonance to both lung field -Auscultationclear
11. Physical examination Heart -Inspection/palpationPMI over the L't 5th ICS mid-clavicular line, no LV heaves. -Auscultationregular rhythm, normal S1, loud S2, no S3, S4 or opening snap. Abdomen -Inspectionno scars,no spider nevi, RUQ superficial vein engorgement.
13. Hospital course-ER Glucose AC AST PT INR aPTT 109 79 12.8 1.22 28.8 Hb HT WBC Seg Lympho cyte 9.0 27.4 3.4 79 13 BUN 10 Creatini ne 0.6
14. ENT consultation 6/16 12:22 ENT finding: Lt neck level II mass 2x2 cm, firm, non-movable Lt parapharyngeal wall tumor with ulceration, no active bleeding A: oropharyngeal tumor r/o EV or GI bleeding Liver cirrhosis P: please trerat medical problem as your expertise 1. arrange PES 2. arrange neck CT or MRI with /without contrast including hypopharynx 3. ENT OPD f/u for further evaluation
15. CT report Evidence of bulky tumor involving left lateral oropharyngeal, hypopharyngeal and laryngeal walls. The origin is hard to defined. Enlarged lymph nodes are noted at submental area, left lateral retrophryngeal space and along left internal jugular chain, level II
16. Gastroscopy 2014/06/16 14:36:42 Active bleeding in the left epiglottis. Suggest ENT for hemostasis and intubation as needed for high risk of suffocation.
17. Laryngeal scope 2014/06/16 18:08: 55 Left hypopharyngeal ca with ulceration and blood clot, no active bleeding Left vocal palsy Airway compromise Diagnosis Left hypopharyngeal ca Suspected GI bleeding Comment Protect airway Embolization if needed
18. Hospital course-ER ABG 60% PEEP 5 pH PaCO2 PaO2 7.553 28.3 178.8 SaO2 99.4% HCO3 BE 24.3 3.1
19. Tentative diagnosis Suspect left hypophargeal cancer with ulceration and active bleeding s/p endotracheal intubation for protect airway Anemia, related tumor bleeding EV s/p ligation without active bleeding Liver cirrhosis, child A History of gastric ulcer
20. MICU Hospital course NG irrigation Blood transfusion on 6/17 -> Hb rise from 7.7 to 9.7 NPO CVP for nutrition
22. Gastroscopy 6/17 21:23pm ESOPHAGUS 1.One protruding mass with blood coating and friable mucosal change at the left side of epiglottis are noted. Mild oozing is found. One pseudo-tract is noted below the right side of pyriform sinus (located upper of the esophageal opening). 2.Two varices (2F1, Cb, Li, RCS(-)) and one fibrotic ring are noted at the EC junction. STOMACH 1.Superficial Gastritis 2.Ulcer
32. Labtory studies Most CBC Infection/Inflammation ESR, CRP, Blood culture, EBV/CMV(adenopathy) Specific serlogy T gondii, Bartonella, Tularemia, TB skin test Bone marrow biopsy hematologic malignancy
33. Image study Ultrasound guide fine needle aspiration CT indentify primary source possible vascular origin MRI soft tissue tissue perineural/CNS PET detect distant metastasis not sensitive in neck mass