Case
Name of the
patient Mammed Koya
Address
Kamukkayam
Thiruvannur
Manari Bypass
Age: 70
years Sex: Male
Admission No:
1317 Date of Admission: 26/ 03/ 05
Presenting
Complaints
1.
Hoarseness of voice (5 months)
Hoarseness with
obstructed feeling in throat
No pain in throat
No dysphagia
Hoarseness <
evening
2.
Redness of left eye (1 month)
No itching
No pain
No lachrymation
There is sand
sensation in left eye.
Dimness of vision
for distant objects
History of
presenting complaint
Complaint started
5 months back. He took allopathic treatment with radiotherapy.
Past History
No relevant
complaints in the past
Family history
No similar
complaint among the family members
Personal History
Born and brought
up at Mankavu. He has the habit of smoking started at the age
of 20. One packet of cigarettes a day and he is still
continuing the habit.
Regionals
Appetite : Good; Desires
pungent food
Thirst : Good
Bowels : Regular
Urine : No complaints
Sweat : N
Thermal
reaction : Not specific
Physical
Examination:
Pulse Rate: 68/
minute Respiratory Rate: 20/ minute
BP: 110/ 70mm of
Hg Temperature : 98.6ºF
General Survey
Moderately built
and nourished
Pallor present
No cyanosis, No
icterus.
No clubbing, No
lymphadenopathy and No pedal oedema.
O/E: Oral cavity
and Oropharynx
Lips (N) Tongue (N)
Gums
(N) Pillars (N) Tonsils (N)
Internal Larynx Examination
Epiglottis
(N)
There is an
ulceroproliferative growth involving the anterior commissures
and anterior ⅔ of medial borders and superior surface of (L)
vocal cord.
Vocal cords mobile
B/L
Neck
No neck node
Carotid palpable
(B/L)
Impression
:
Carcinoma Larynx T2
N0
M0
Biopsy
:
Squamous cell Carcinoma-
moderately differentiated
Systemic
Examination
Examination of
Respiratory system
Examination of
Upper Respiratory tract
No congestion of
nasal mucosa, no deviation of nasal septum& no nasal polyp
Uvula centrally
placed & no tonsillar enlargement.
Examination of
lower Respiratory tract
Inspection
Trachea appears to
be centrally placed
Chest wall
bilaterally symmetrical
No kyphosis,
scoliosis or lordosis; no prominent vessels and visible
pulsations.
Palpation
No palpable
swelling; Trachea centrally placed; Apex beat palpable.
Percussion
Normal lung
resonance
Auscultation
No wheeze heard
Examination of
Central Nervous system
Examination of
higher mental functions
Patient is
conscious, intelligent, normal behaviour, past and present
memory present, orientation of time, place and person present,
no hallucination, delusion, illusion and speech normal.
Examination of Cranial nerves
Olfactory Nerve
No anosmia,
parosmia and hallucination of smell.
Optic Nerve
There is no
obstruction on the field of vision
Oculomotor Nerve, Trochlear
Nerve, Abducens
Ocular movements
are within normal limits, no nystagmus. Pupil reacts to light.
Trigeminal Nerve
Sensation over
face is intact; corneal and conjunctival reflexes intact.
Jaw jerk present
Facial Nerve
Eye closure,
frowning, raising the eye brow present
Can blow, whistle
and show the teeth
Vestibulocochlear Nerve
No impairment of
hearing
Glosopharyngeal Nerves and
Vagus
Gag reflex present
Uvula centrally
placed
Hypoglossal Nerve
Can move tongue in
all directions
Sensory System:
With in normal
limit
Examination of
motor System:
Within normal
limits
Signs of meningeal
irritation:
No signs of
meningeal irritation
Analysis of symptoms
Symptoms of
disease
|
Symptoms of
patient
|
Hoarseness
of voice
|
Desires
pungent things
|
Hoarseness
of voice< evening
|
Evaluation of symptoms
|
Physical
generals |
Particulars |
Common
symptoms |
|
Desires
pungent things |
Redness of
left eye |
Hoarseness
of voice |
Totality of Symptoms
