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  • Eng - Kronoligis Ani Manurung

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    Andi Imam Buchari nst
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    The patient experienced difficulty and pain swallowing for several weeks and was admitted to the hospital. Medical tests found a mass in the patient's esophagus that was pushing on the trachea and constricting the esophageal lumen. Over the course of a week in the hospital, the patient underwent CT scans and consultations with various specialists. It was determined that the patient likely had esophageal cancer or a laryngeal tumor. The patient refused a proposed gastrostomy procedure but eventually consented. Biopsy and further tests were planned to confirm the diagnosis before determining next steps.

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    ENG- KRONOLIGIS ANI MANURUNG

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    The patient experienced difficulty and pain swallowing for several weeks and was admitted to the hospital. Medical tests found a mass in the patient's esophagus that was pushing on the trachea and constricting the esophageal lumen. Over the course of a week in the hospital, the patient underwent CT scans and consultations with various specialists. It was determined that the patient likely had esophageal cancer or a laryngeal tumor. The patient refused a proposed gastrostomy procedure but eventually consented. Biopsy and further tests were planned to confirm the diagnosis before determining next steps.

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    22 views9 pages

    Eng - Kronoligis Ani Manurung

    Uploaded by

    Andi Imam Buchari nst
    The patient experienced difficulty and pain swallowing for several weeks and was admitted to the hospital. Medical tests found a mass in the patient's esophagus that was pushing on the trachea and constricting the esophageal lumen. Over the course of a week in the hospital, the patient underwent CT scans and consultations with various specialists. It was determined that the patient likely had esophageal cancer or a laryngeal tumor. The patient refused a proposed gastrostomy procedure but eventually consented. Biopsy and further tests were planned to confirm the diagnosis before determining next steps.

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    © All Rights Reserved
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    of 9

    ANI MANURUNG’S TIMELINE

    Day/Date Follow up Information


    Tuesday/26-01-21 S : Hard to swallow Supervisor in charge :
    This complaint has happened dr. M. Arfiza P Saragih,
    since 2 weeks before Sp.THT.KL
    admission. Patient also
    complained painful
    swallowing since 1 week
    before admission and
    coughing while trying to
    ingest either food or liquid.
    Patient experienced a 2 kg
    weight loss for the last 2
    weeks before admission.
    Patient was referred from
    RSUD Tarutung

    O : Oropharynx :
    Pharynx : Normal
    Tonsil : T1/T1

    A : Dysphagia e.c.
    esophageal tumor

    P : SPV’s advice:
     Admit to inpatient unit
     Biopsy preparation
     NGT insertion (do not
    succeed)
     Neck CT-Scan with
    contrast

     IVFD RL 20 gtt/i
     Inj. Ketorolac 30 mg/8h
     Inj. Ranitidin 50 mg/12h
     Inj. Cernevit /24 h
    Wednesday/27-01-21 S : Difficult to swallow (+), - Schedule Neck CT-Scan
    painful swallowing with contrast
    decreased, fatigue(+) - Clinical Nutritionist
    advice:
    O : Oropharynx : Nutrients needed calories
    Pharynx : Normal 1040 kkal (20 kkal/kg),
    Tonsil : T1/T1 protein 56g (1,1g/kg), fat
    20%, carb 150g through
    A : Dysphagia e.c. perifer parenteral, berupa:
    esophageal tumor
    Clinimix 15E 2000 ml/24h
    P : SPV’s advice: Cinoleic 100ml/24 h
    - IVFD RL 20 gtt/i (Cinoleic is added into
    - Inj. Ketorolac 30 mg/8h clinimix 1000 ml finished
    - Inj. Ranitidin 50 mg/12h within 12h).
    - Inj. Cernevit /24 h Advice: to do gastrostomy
    - Consult to Clinical or instal central parenteral
    Nutritionist for parenteral pathway
    nutrition
    Thursday/28 -01-21 S : Difficult to swallow (+), Performed Neck CT-Scan
    painful swallowing today.
    decreased, fatigue (+)

    O : Oropharynx :
    Pharynx : Normal
    Tonsil : T1/T1

    A : Dysphagia e.c.
    esophageal tumor

    P : SPV’s advice:
    - IVFD RL 20 gtt/i
    - Clinimix 15E 2000 ml/24h
    - Inj. Ketorolac 30 mg/8h
    - Inj. Ranitidin 50 mg/12h

    Friday/29-01-21 S : Difficult to swallow (+), Waiting for CT-Scan result


    Painful swallowing
    decreased, fatigue (+)

    O : Oropharynx :
    Pharynx : Normal
    Tonsil : T1/T1

    A : Dysphagia e.c.
    esophageal tumor

    P : SPV’s advice:
    - IVFD RL 20 gtt/i
    - Clinimix 15E 2000 ml/24h
    - Inj. Ketorolac 30 mg/8h
    - Inj. Ranitidin 50 mg/12h

    Saturday/30-01-21 S : Difficult to swallow (+), Neck Ct-Scan Leher with


    Painful swallowing contrast (28-01-21) :
    decfreased - Trachea was pushed by
    a mass on the posterior
    O : Oropharynx : trachea. Esophageal
    Pharynx : Normal lumen was constricted.
    Tonsil : T1/T1 Mass’s origin may still
    from esophagus.
    A : Dysphagia e.c.
    esophageal tumor

    P : SPV’s advice:
    - IVFD RL 20 gtt/i
    - Clinimix 15E 2000 ml/24h
    - Inj. Ketorolac 30 mg/8h
    - Inj. Ranitidin 50 mg/12h
    - Plan to do biopsy
    - Plan to do swab

    Sunday/31-01-21 S : Difficult to swallow (+),


    Painful swallowing decreased

    O : Oropharynx :
    Pharynx : Normal
    Tonsil : T1/T1

    A : Dysphagia e.c.
    esophageal tumor

    P : SPV’s advice:
    - IVFD RL 20 gtt/i
    - Clinimix 15E 2000 ml/24h
    - Inj. Ketorolac 30 mg/8h
    - Inj. Ranitidin 50 mg/12h
    - Plan to do biopsy

    Senin/ 01-02-21 S : Difficult to swallow (+) Pulmonologist’s advice :


    A : Esophageal Tumor dd
    O : Oropharynx : Laryngeal Tumor
    Pharynx : Normal P : waiting for Blood Gas
    Tonsil : T1/T1 Test result

    A : Dysphagia e.c.
    esophageal tumor Interna Cardio’s advice :
    A:
    P : SPV’s advice: - Esophageal Tumor dd
     IVFD RL 20 gtt/i Laryngeal Tumor
     Clinimix 15E 2000 ml/24h - Asymptomatic Bradycardia
     Biopsy preparation: P : surgical tolerance 
    - Consult to Interna Moderate risk
    Cardio (surgical
    tolerance)
    - Consult Digestive Surgeon’s advice :
    Pulmonologist A : Esophageal Tumor dd
    (surgical tolerance) Laryngeal Tumor
    - Consult to Digestive P : patient refused
    surgery (surgical gastrostomy procedure
    tolerance)
    - Swab PCR Covid-19

    Tuesday / 02-02-2021 S : Difficult to swallow (+) AGDA :


    pH/pCO2/HCO3 :
    O : Oropahrynx : 7,48/36/26.8
    Pharynx : Normal
    Tonsil : T1/T1 Pulmonologist’s advice :
    A : esophageal tumor dd/
    A : Dysphagia e.c. laryngeal tumor
    esophageal P : surgical tolerance: Low-
    Moderate Risk
    P : SPV’s advice:
    - IVFD RL 20 gtt/i Digestive surgeon (re-
    - Clinimix 15E 2000 ml/24h educate)
    - Biopsy preparation A : GIO dd esophageal
    - Lab check (complete tumor dd laryngeal tumor
    blood work, random T4N0M0
    glucoses, renal function, P : - Consult to anasthesia
    electrolytes). (install CVC, diet through
    TPN)
    - Gastrostomy
    Feeding
    - Advice to consult to
    GEH (Esofagoscopy
    Biopsy)

    Swab PCR result : Negative


    Wednesday/ 03-02- S : Difficult to swallow (+) Laboratorium
    2021 Hb/L/T : 10,5/2870/188000
    O : Oropharynx: Random blood glucose : 75
    Pharynx : Normal Ur/Cr : 21/ 0,56
    Tonsil : T1/T1 Na/K/Cl : 139/ 4,3/104
    Blood Gas test:
    A : Dysphagia e.c. pH/pCO2/HCO3 :
    esophageal tumor 7,47/35/25.5

    P : SPV’s advice:
    - IVFD RL 20 gtt/i
    - Clinimix 15E 2000 ml/24h
    - Plan to do biopsy in
    Operating Theatre
    - Consult to Digestive
    Surgeon (patient
    consented to a
    gastrostomy procedure)

    Thursday/04-02-2021 S : Difficult to swallow (+) Digestive Surgeon’s advice :


    A : GIO + Susp. Esophageal
    O : Oropharynx : Ca T4N0M0
    Pharynx : Tenang P:
    Tonsil : T1/T1 - Gastrostomy Feeding
    emergency
    A : Dysphagia e.c. - Consult to
    esophageal tumor anesthesiologist Install CVC
    diet TPN
    P : SPV’s advice: - Consult to GEH:
    - IVFD RL 20 gtt/i Esophagoscopy + Biopsy,
    - Clinimix 15E 2000 ml/24h Gastrostomy Feeding
    - Agree that biopsy will be (emergency)
    performed by Interna
    GEH Anesthesiologist’s reply :
    - Consult to Digestive A : Susp. Esophageal Ca
    Surgeon to take over this P : agree to perform
    patient anesthesia procedure

    Friday/ 05-02-2021 S : Difficult to swallow (+) Waiting for Digestive


    Surgeon’s advice
    O : Oropharynx :
    Pharynx : Normal GEH’s advice :
    Tonsil : T1/T1 A : Susp. Esophageal Ca
    P : - Scheduling
    A : Dysphagia e.c. esophagoscopy + biopsy in
    esophageal tumor + Post IDT
    gastrostomy feeding - Agree to manage this
    patient
    P : SPV’s advice:
    - IVFD RL 20 gtt/i
    - Clinimix 15E 2000 ml/24h
    - Pursuing Digestive
    Surgeon’s advice

    Saturday /06-02-2021 S : Difficult to swallow (+) Waiting for Digestive


    Surgeon’s advice
    O : Oropharynx :
    Pharynx : Normal Plan to perform
    Tonsil : T1/T1 esophagoscopy + biopsy in
    IDT by GEH
    A : Dysphagia e.c.
    esophageal tumor + Post
    gastrostomy feeding

    P : SPV’s advice:
    - IVFD RL 20 gtt/i
    - Clinimix 15E 2000 ml/24h
    - Pursuing Digestive
    Surgeon’s advice

    Sunday/07-02-2021 S : Difficult to swallow (+) Digestive Surgeon’s advice :


    A : Post Gastrostomy
    O : Oropharynx : Feeding + Susp Esophageal
    Pharynx : Normal Cancer +GIO
    Tonsil : T1/T1 P : Do not agree to take
    A : Dysphagia e.c. over this patient, waiting
    esophageal tumor + Post for esophagoscopy result
    gastrostomy feeding from GEH.

    P : SPV’s advice:
    - IVFD RL 20 gtt/i
    - Clinimix 15E 2000 ml/24h
    Monday/08-02-2021 S : Difficult to swallow (+) GEH:
    A : Susp. Esophageal Cancer
    O : Oropharynx : + Iron deficiency anemia dd
    Pharynx : Normal chronic disease
    Tonsil : T1/T1 P : - Consult to HOM
    (esophageal biopsy
    A : Dysphagia e.c. tolerance
    esophageal tumor + Post - Consult to
    gastrostomy feeding anesthesiologist
    - Hemorrhagic
    P : SPV’s advice: screening test
    - IVFD RL 20 gtt/i - Consult to clinical
    - Clinimix 15E 2000 ml/24h nutritionist
    (hypoalbumin)

    HOM’s advice:
    A : Hypocoagulation status
    P : esophagoscopy
    tolerance low to
    moderate risk

    Clinical Nutritionist advice :


    P : Tropic Feeding using
    Peptamen 100/4 h.
    Administer gradually based
    on gastric intake capacity

    Anesthesiologist’s advice :
    A : esophageal tumor
    P : agree to perform
    anesthesia procedure
    Tuesday/ 09-02-2021 S : Difficult to swallow (+) GEH:
    A : Susp. Esophageal Cancer
    O : Oropharynx : + Iron deficiency anemia dd
    Pharynx: Normal chronic disease+Status
    Tonsil : T1/T1 hipokoagulasi +hipoalbumin
    P : Esofagoscopy Biopsi hari
    A : Dysphagia e.c. ini di IDT
    esophageal tumor + Post
    gastrostomy feeding

    P : SPV’s advice:
    IVFD RL 20 gtt/i

    Rabu/ 10-02-2021 S : Sulit menelan (+) GEH:


    A : Susp. Esophageal Cancer
    O : Orofaring : + Anemia Def.Besi dd
    Faring : Tenang Penyakit Kronik +
    Tonsil : T1/T1 Hypocoagulation status +
    hypoalbumin
    A : Dysfagia e.c. Tumor P : follow up biopsy result
    esofagus + post gastrostomy
    feeding + post esofagoskopi
    biopsi

    P : Advis DPJP:
    IVFD RL 20 gtt/i
    Waiting for biopsy result
    Thursday/ 11-02-2021 S : difficult to swallow (+) Histopathologic result :
    Squamous Cell Carcinoma
    O : Orofpharyng : (Keratinizing)
    Pharyng : normal
    Tonsil : T1/T1 GEH :
    A : Esophageal Carcinoma
    A : Dysphagia e.c. P : Off managing this
    esophageal tumor patient from GEH Division

    P : SPV’s advice:
    IVFD RL 20 gtt/i
    Friday/ 12-02-2021 S : Difficult to swallow (+)

    O : Oropharynx :
    Pharynx : Normal
    Tonsil : T1/T1

    A : Esophageal Ca + post
    gastrostomy feeding

    P : Advis DPJP:
    - IVFD RL 20 gtt/i
    - Waiting for biopsy result
    - Consult to Digestive
    Surgeon to take over this
    patient
    Saturday/ 13-02-2021 S : Difficult to swallow (+) Digestive Surgeon’s advice :
    Do not agree to take over,
    O : Oropharynx : discharge patient and
    Pharynx : Normal control to digestive
    Tonsil : T1/T1 outpatient unit

    A : Esophageal Ca + post
    gastrostomy feeding

    P : Advis DPJP:
    - IVFD RL 20 gtt/i
    - Agree to discharge this
    patient
    - Control to Digestive
    Surgery outpatient unit
    Monday, 15-02-2021 S : Difficult to swallow (+)

    O : Oropharynx :
    Pharynx : Normal
    Tonsil : T1/T1

    A : esophageal Ca

    P : SPV’s advice
    Consult to digestive
    outpatient unit
    Friday, 19-02-2021 S: difficult to swallow Digestive’s reply:
    Do not agree to take over
    O : Oropharynx :
    Pharynx : Normal
    Tonsil : T1/T1 ENT Oncology Division’s
    advice:
    A : esophageal Ca Please re-consult during
    working hours to re-
    P : SPV’s advice evaluate on February 22,
    Consult to ENT Oncology 2021. Returning to
    Division Pharyngeal Larynx Division.
    Monday, 22-02-2021 S: difficult to swallow

    O : Oropharynx :
    Pharynx : Normal
    Tonsil : T1/T1

    A : esophageal Ca

    P : Advis DPJP:
    Consult to Oncology Division

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