CHAPTER II - Nasopharyngeal CA

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Name : Mr. I

Age : 43 y.o

MR : 76 96 15 Gender : Male

Tribe : Minangkabau

Adress : Pesisir Selatan


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A male patient came to Dr. M. DjamilHospital on June 11th2014 with:

Main Complaint Patient was suggested by the radiotherapist

to do blood transfusion before continuingthe therapy.


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Patient has noticed as a nasopharyngeal carcinoma non

keratinizing stage IV B (T2N3aMO) durante 20th

Radiotherapy, thelaboratory finding has informed that Hb: 9,6 g/dl and he suggestedto do blood transfusion.

Patient has done the chemotherapy for twice.

Lump in the right side of neck since 5 month ago, and gettingsmaller after the radiotherapy.

The right ear feels blocked since 4 month ago.

There is history of nose blockage in the right cavity and it continuedto the left cavity about 4 month ago, and it lesser after theradiotherapy.

There is history of blood stained nose discharge about 4 month ago

and it doesnt happen anymore after the radiotherapy. There isnt difficulty to open mouth.

There isnt lump in armpits and groins.

Intermittent headache in the right side of head since 2 month ago.

There isnt history of blurred vision and double vision.

There isnt difficulty to swallow.


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Past Medical History

Lump in the right neck 2 years ago and he

had chemotherapy for 8 times in internalmedicine department. The lump appearedagain 4 months after the chemotherapy.

Family Medical History

There isnt any family member who hasmalignant disease.


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Social, Economic, and Habit History

The patient is a trader.

There isnt history of consuming salted fishroutinely.

History of consuming alcohol is present, forabout 10 ten years, about 1 glass per day.

History of consuming cigarette is present, forabout 20 years, about 1 box per day.

There isnt exposure of wood dust.


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General Status General appearance : Moderate ill

Consciousness : Composmentis Cooperative

Blood pressure : 120/70 mmHg

Pulse : palpable, regular, 82 times per minute

Respiration : abdominotoracal, regular, 19

times per minute Temperature : 36,90C

Height : 162 cm

Weight : 54 kg


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Systemic Examination Eyes : Anemic conjunctiva (-), icteric sclera (-

)

Neck : Coli (d) region, level II-III: mass (+),size: 4x4x1 cm, solid, fixed, tenderness (-),hyperpigmentation (+)

Pulmo : normal

Cardio : normal

Abdomen : normal

Extremities : warm acrals, good perfusion


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Auricle

Congenital abn. - -

Trauma - -

Inflammation - -

Metabolic abn. - -

Pain tensile - -

Tragus tenderness

-

-

Ear canal

Wide + +

Narrow

Hyperemia

Edema

Mass

Discharge/Cerum

en

Smell - -

Color -

-

Amount - -

Type - -


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Tympani Membrane

Intact

Color grey white

Light reflex

-

+

Bulging - -

Retraction - -

Atrophy - -

Perforation

Numbers

-

-

Type

Quadrant

Edge


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Mastoid Inflammation - -

Fistula - -

Scar - -

Tenderness - -

Tap pain - -

Tuning fork test

Rinne - +

Schwabach longer same

Weber right lateralization

Conclusion Conductive hearing loss

Audiometry


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Nose

External nose

Deformity - -

Congenitalabn.

-

-

Trauma - -

Inflammation - -

Mass -

-

Paranasal Sinuses

Tenderness - -

Tap pain - -


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Anterior Rhinoscopy

VestibulumVibrissae +

+

Inflammation - -

Nasal cavity

Plenty wide + +

Narrow

Wide

Discharge

Location - -

Type

Amount

Smell

Inferior concha

Size eutrophy eutrophy

Color pink

pink

Surface sleek sleek

Edema - -

Media concha


Color pink pink

Surface sleek sleek

Edema -

-


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Septum

Straight/

Deviation

- -

Surface - -

Color - -

Spine - -

Crest - -

Abscess - -

Perforation - -

Mass

Location - -

Shape

Size

Surface

Color

Consistency

Easily swayed

Constrictor effect


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Posterior Rhinoscopy

Choana

Plenty wide

Narrow + +

Wide

Mucous

membrane

Color

pink

pink

Edema - -

Granulation

tissue

- -

Inferior concha


Color pink pink

Surface sleek sleek

Edema - -

Adenoid Present/Not not not


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Mouth of

Eustachian tube

Closed by

discharge

closed by

mass

-

Mucous edema

-

-

Mass

Location nasopharynx dextra

Size Closing almost half of

nasopharynx

Shape irregular

Surface irregular

Post nasal dripPresent/Not not not

Type


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Palatum molle +

pharyngeal arch

Symmetrical/Not symmetrical symmetrical

Color pink pink

Edema - -

Spotted/Exudate -

-

Pharyngeal wall

Color pink pink

Surface sleek

sleek

Tonsil

Size T1 T1

Color pink pink

Surface sleek sleek

Mouth of cripti

no widening

no widening

Detritus - -

Exudate - -

Adhesion to the

pillars

- -

Peritonsil

Color pink pink

Edema - -

Abscess -

-


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Tumor

Location - -

Shape

Size

Surface

Consistency

TeethCaries/radix + +

Impression bad hygiene bad hygiene

Tongue

Color pink-red

pink-red

Shape normal Normal

Deviation - -

Mass - -


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Indirect Laryngoscopy

Epiglottis

Shape omega omega

Color pink pink

Edema -

-

Edge flat flat

Mass - -

Arytenoid

Color white white

Edema - -

Mass -

-

Movement normal normal

Ventricular band

Color pink pink

Edema - -

Mass - -


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Plica vocalis

Color white white

Movement - -

Medial edge - -

Mass white white

Subglottis/

trachea

Mass - -

Discharge - -

Pyriform sinus

Mass - -

Discharge - -

ValleculaMass - -

Discharge - -


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Lymph Nodes Examination

By the inspection, a lymph node can be

seen in coli (d) region, level II-III By the palpation, a mass of lymph node was

present, size: 4x4x1 cm, solid, fixed,tenderness (-)


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History Patient has noticed as a nasopharyngeal

carcinoma non keratinizing stage IV B (T2N3aMO)

durante 20thRadiotherapy, the laboratoryfinding has informed that Hb: 9,6 g/dl and hesuggested to do blood transfusion.

Patient has done the chemotherapy for twice.

Lump in the right side of neck since 5 monthago, and getting smaller after the radiotherapy.

The right ear feels blocked since 4 month ago.

Intermittent headache in the right side of headsince 2 month ago.


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Physical Examination Ear (d) : tympani membrane: grey, light reflex (-),

rinne: (-), weber: right lateralization, swabach:

longer than the examiners Ear (s) : tympani membrane (s): white, light reflex

(+),rinne: (+), weber: right lateralization,swabach: same as the examiners

Nose : posterior rhinoscopymouth ofEustachian tube (d): closed by mass, mass: innasopharynx dextra, size: closing almost half ofnasopharynx, shape: irregular, surface: irregular.

Throat : normal


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Working Diagnosis

Nasopharyngeal Carcinoma Non-Keratinizing Stage IV B (T

2N

3aM

O) Durante 20th

Radiotherapy Pro Transfusion Susp.Intracranial Metastasis

Additional Diagnosis

Conductive Hearing Loss

Differential Diagnosis

-


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More Examination CT-scan: nasopharyngeal tumor spreading

to hypopharynx dextra

Histopatology: squamous cell carcinoma ofnasopharynx non-keratizing welldifferentiated.

Suggested Examination Periphery blood examination

Brain CT-Scan

Audiometry


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Therapy Dexamethasone pre transfusion (2 x 1 ampul 5 mg)

Transfusion of 2 units PRC (2 x 1 unit)

Radio-chemotherapy

Prognosis Quo ad sanam : dubia at malam

Quo ad vitam : dubia at malam

Quo ad fungsionam : dubia at malam

Education To continue the therapy regularly.

Stop smoking and drinking alcohol, and having ahealthy life: doing exercise 3-5 times in a week,consuming vegetables and fruits.

Documents

CHAPTER II - Nasopharyngeal CA