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Case #4

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Expand Physical Exam

05/10/XX

Hoarseness; difficulty breathing for two weeks. No apparent lymphadenopathy.

Expand X-Rays & Scans

05/10/XX

Upper GI: apparent mass extending to esophagus, otherwise unremarkable.

05/10/XX

CXR: Lungs are clear. No evidence of disease.

Expand Scopes

05/10/XX

Direct laryngoscopy and biopsy of laryngeal mass. Findings: fungating mass on right posterior aryepiglottic fold, arytenoid cartilage and anterior half of esophageal inlet.

05/17/XX

Total laryngectomy with bilateral neck dissection.

Expand Laboratory

None

Expand Operative Findings

05/17/XX

No obvious residual unresected tumor.

Expand Pathological Reports

05/10/XX

Biopsy of supraglottic mass: Squamous cell carcinoma with areas of necrosis.

05/17/XX

Total laryngectomy: squamous cell carcinoma, moderately differentiated, penetrates esophagus approximately 2 cm, 0/39 right and left lymph nodes positive.

Expand Treatment

05/17/XX

Surgery: Total laryngectomy and bilateral neck dissection

06/29/XX

Radiation: began IMRT 63 Gy to head and neck