Admitting history

Our patient is Estella Vargas, a 52 years old, female, Filipino, catholic from Novaliches
Quezon City.

Chief Complain: Anterior muscle mass, right

History started 22 y/o. PTA, when patient noted a marble size mass on the neck mass
right, no associated symptom noted, no consult done, no meds.

2 months PTA, patient noted a gradual enlargement of the mass accompanied by

dysphagia to solid and liquids odynophagia, hoarseness OCC( dyspnea). This prompted
consult at ENT EAMC. Goiter work up done. Given unrecalled mads for symptoms wiyh
provided resolution/ relief.

1 month PTA, progression in size of the mass prompted another consult at ENT OPD.
Head and neck Subspecially. Patient was advised surgery hence this admission.

ROS:

+ wt loss
- Dysphagia
- Dyspnea
- Fever
- Odynophogia
+ colds
+ hoarseness

PMHX:
- Hypertension, PTB, DM
- Previous surgeries
+ allergy to amoxicillin

FMHX :
V/2 –HPN, DM,PTB, BA
PSHX:
V/R
 Discharge
Vargas, Estrella
652 D
52 years old
Sex: Female
2-14-11

Take Home Meds and instruction on administration

Medicine: Route Time
1. Ciprofluxacin 500 mg 1 tab, tablet 2x a day NGT 9am-5pm
2. Erdostein 300 mg/ cap 1 capsule 2x a day NGT 9am-5pm
3. Omeprazole 40 mg/ cap 3 x a day NGT 9am
4. Kalium Durule 2 cap 3 x s day NGT 9am-1pm-5pm
5. Methylpudnisolone 16mg/ tab 1 tab 1 x a day 9am
Then 12 mg once a day for 2 days 9am
8 mg once a day for 2 days 9am
4 mg once a day for 2 days then discontinue 9am
6. Metronidazole 500 mg/ tab 1 tab 3 x a day for 1 week 9am-1pm-5pm

Diet: Kumain ng pagkaing mayaman sa potassium

Health Teaching:
1. Daily vinegar gargle
2. Tracheostomy care
3. Maintain Pressure dressing

Labaratory: Repeat serum potassium

Clinic appointment:
 Follow up after 1 week Tuesday (Head and neck)
 Follow up sa OPD pulmo Service (tues/ thurs 5am

Discharge Summary

Clinical Abstract: Our patient is a 52 years old, female, married, Filipino, catholic, residing at 23 T.
Alfonzo St. Sta lucia Nove, Quezon City. She come in due to anterior neck mass. Assessment was MNTG.
She was subsequently admitted.
Laboratory Exam
2/13/11 2/11/11 2/11/11 2/30/11 2/1/11 2/09/11 1/12/11 2/5/11
Tp 77.0 BUN 13.7 K 2.9 Na 141 ETA GS/CS K 4.50 FBS BUN
g/L Crea 0.96 K 2.7 GS pus 6.25 97.85mg/dL 17.37
AB 6.3 K 3.10 Sq cells 0.3 BUN 7.28 Crea
Glob 70.7 mg dL 5.87
AIG 0.1 Crea 0.72 K 2.50
Choles
184.17
Trig 174.35
HDL 30.50
LDL 11.8
Na 141
K 4.18

Medication:

 Medsol 4.16 mg 1 tab TID OD

 Kalium durule TID 3X a day
 Losartan 50mg 1 tab OD
 Ciprofloxacin 500 mg 1 tab OD
 Metronidazole 500 mg q8
 CaCo3 tab OD
 Ceftazidime 1 g/ IV OD; 500 g/ IV q8
 Ranitidine 150 mg/ tab q8
 Gentamicin 80 mg/ IV q 8
 Ketorolac 30mg/IV OD
 Omeprazole 40 mg/ IV OD
 FeSO4 OD

FINAL DIAGNOSIS:

Papillary Thyroid Cancer S/P Total Thyroidectomy with Central neck dissection under General
anesthesia
Course In Ward

Upon admission, work ups was due. Patient was refered for CP clearance and was schedule for Total
Thyroidectomy. The following day patient andenocut Total Thyroidectomy with Neck Dissection under
general anesthesia. There were no preoperative and post operative complication noted. On the 3 rd
day HD(2nd post op day). Patient developed fever, and an elevated Bp of 150/90. And RR-28. She was
started on Co- amoxiclav 625 mg/cap TID, all meds. Patient was encouraged deep breathing exercise
and was transferred back to the wards. She was refered to pneumo Dept for management. On the 4 th
HD, CBC showed leucocytosis(14.19) wuth neutophilia(0.94) and slight anemia (hg 98, Net 0-31) upon
examination, she also had hematoma at the base tissue, diffuse laryngeal edema, epiglottis,
arytheuditis and marked decreasein growth inlet. He was given cold liquid diet, IV, oral meds,
nebulization PNSS, and or inhalation were continued. On the 6th HD, patient was placed on NPO and
NGT was inserted, ceftriaxone 750mg/IV OD was started. He was also started on metronidazole 300 g
q8 and pressure dressing at the right neck was placed. On the 7 th HD, repeat CBC with PC showed
hyponatremia correction was done. On the 8th HD, tracheal aspirate GS/CS was ingested and Patient
started on incresase CHON diet and nebulization decrease to BID. On the 12 th HD, patient developed
cough with yellowish sputums occasionally with blood . Assessment was hospital Acquired
pneumonia(pseudomonas) papillary CA, tracheostomy, hypobulemia. Patient was started on
endosteine900 mg/ cap BID, Salbutamol + imatrupin q8 with hourly suctioning. On the 15 th HD,
creatininewas noted to be elevating, antibiotics were adjusted to oral dose. Works ups were
suggested for cause of azotenia: FBS, LP, CBC monitoring, KUB. He was started on Ceftazidime 1g/IV
OD and gentamycin discontinued. Patient was refused to nephrology dept; he was started on lozartan
50mg 1 tab oral and other IV meds were continued.

Consultation Remarks:

This is a case of Vargas Estella 52, F was admitted due to enlarging neck mass.
20 years PTA- gradually enlarging anterior neck mass, (-) dysphagia
Decrease (-) DOB several consults done, she was advised for observation

2months PTA- (+) hoarseness, (+) DOB

2weeks PTA- (+) wt. loss, (+) cough/fever

ROS:
Direct abdominal intolenrance (-) trismus, (-) constipation, (-) diarrhea

PMAX:
(-)HPN, DM,PTB,BA
SHX:
(-)smoke, alcohol drinker