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Case #2

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Expand Physical Exam

03/12/XX

ENT: Oropharynx showed presence of granular lesion involving lateral aspect of uvula creeping towards edge of soft palate and onto posterior pillar on the left side. No lymphadenopathy.

Expand X-Rays & Scans

03/12/XX

CXR: Question of nodule in right lower lobe. CT Neck: questionable minimal soft tissue thickening without gross evidence of enhancement within the left lateral aspect of soft palate and uvula. No evidence of neck lymphadenopathy.

Expand Scopes

03/12/XX

Direct laryngoscopy with biopsy of soft palate and uvula. Findings: granular lesion of soft palate appears to be involving uvula.

Expand Laboratory

None

Expand Operative Findings

03/12/XX

Excision of palatal carcinoma, tonsillectomy, palatal pharyngoplasty. Findings: Palatal carcinoma involving uvula extending along left edge of soft palate onto anterior and posterior pillar with no direct infiltration of tonsil.

Expand Pathological Reports

03/12/XX

Micro: Infiltrating moderately to poorly differentiated focally keratinizing squamous cell carcinoma arising from epithelium of uvula. Deep margins free. Epithelial margins negative. Tumor size 1.0 cm.

Expand Treatment

03/22/XX

Surgery: Excision of palatal carcinoma, tonsillectomy, palatal pharyngoplasty.