A MAN 59 YEARS OLD WITH RECURRENCE SUBMANDIBULA

SALIVARY GLAND TUMOR, HEPATOMEGALY AND ANEMIA

By:
Anthony Johan
G99161018

Supervisor:
Dr. dr. Kristanto Yuli Yarsa, Sp. B (K) Onk.

DEPARTMENT OF SURGERY
FACULTY OF MEDICINE UNS/ RSUD DR. MOEWARDI
SURAKARTA
2017
 Medical Record

A. Anamnesis
1. Patient Identity
Name : Mr. S
Age : 59 years old
Sex : Man
Address : Koriwetan, Ponorogo, East Java
Job : Farmer
Medical Record Number : 0138xxxx

2. Chief Complain
Mass on the right jaw

3. Present Illness
Patient referred to Moewardi Hospital from Aisya Hospital,
Ponorogo with description of Adenoid Cystic Carcinoma. There is a
mass on the right jaw with size as big as a tennis ball. The mass appear
from 3-4 years ago. Its original size as big as a pingpong ball, and the
mass got bigger slowly since then. The patient not complaining about
odinofagia or disfagia, although the patient feels that the tumor has
spreading into his ginggiva. Patient didnt feel any move limitation
from the jaw. Patient didnt feel any pain from the tumor location. The
mass occasionally bleed with fresh coloured blood. Patient didnt feel
any hearing loss, vision loss, change of food taste, or any difficulty to
breath or talking. There is no limitation in facial expression. Patient
weight decreased from 70 kg (2-3 months) to 49 kg (this month).
Patient feel pain in the right thigh, limiting his movement. Patient
often feeling nauseous (but not vomiting), lowering his appetite. No
complain in defecation and urinating.
 Patient is a heavy smoker that stop his habit in this past 2
months. Patient have been smoking cigarette from middle school, and
can smoke 1-2 packs of cigarette per day.

4. Past Illness History

History of same illness : (-)
History of allergic : (-)
History of hypertension : (-)
History of diabetes mellitus : (-)
History of heart disease : (-)
History of operation procedure : (+)
In 2013 patient have undergo an operation at Aisya Hospital in
Ponorogo. But theres no summary of the operation. Before the
operation patient undergo a FNAB with result of Adenoid Cystic
Carcinoma of the submandibula salivary gland.

5. Familys Illness History

History of same illness : (-)
History of allergic : (-)
History of hypertension : (-)
History of diabetes mellitus : (-)
History of heart disease : (-)
History of tumor : (-)

6. Economic and Social History

Patient is a farmer. Now, He lives together with his daughter and her
family. Patient eat 3 meals a day with balance nutrition composition.
Patient treated in Moewardi Hospital by using BPJS.
B. Physical Examination
1. Consciousness : compos mentis
General condition : moderate
Performance status based on Karnofsky score : 60%
(Requires occasional assistance, but is able to care for most of his
needs)

2. Vital sign
Blood pressure : 110/70 mmHg
Heart rate : 80 x/ minute
Respiratory rate : 20 x/ minute
Temperature : 36,30C per axilla

3. Nutritional status
Weight : 49 kg
Height : 165 cm
BMI : 17,99 (underweight)

4. General Survey
Head : mesocephal
Eyes : anemic conjunctiva (+/+), icteric sclera (-/-)
Ears : normotia, inflammation (-/-), secret (-/-)
Nose : symmetric, inflammation (-/-), secret (-/-)
Mouth : sianotic (-)
Jaw : see localized status
Neck : lymph nodes in the neck area not palpable
Thorax : normochest, symmetric
Pulmo
Inspection: movement of hemithorax left = right, retraction (-/-)
Palpation: fremitus tactile right = left
Percussion: sonor/ sonor
 Auscultation: vesicular base sound (+/+), additional sound (-/-)
Heart
Inspection: ictus cordis not visible
Palpation: ictus cordis is palpable, thrill (-)
Percussion: heart border normal
Auscultation: heart sound I-II regular, additional sound (-)
Abdomen :
Inspection: scar (-), inflammation (-), distended (-)
Auscultation: bowel sound (+) normal, 11 x/ minute
Percussion: tympanic, liver span 16 cm
Palpation: pain (-), liver palpable (pain +), spleen not palpable

C. Localized Status
R. Mandibular Dextra
Inspection : mass on the right jaw as big as tenis ball, iregular surface,
same colour with surrounding area, bleeding (-), eritem (-)
Palpation : mass was palpated, its size: 16 x 15 x 5 cm, immobile,
ireguler surface with hard consistensy, pain (-), warmer
than the body temperature. Jaw area around the mass
swollen with warm temperature, pain (-).
 R. Oral
Inspection : mass originated from ginggiva, bleeding (-), eritem (-)
Palpation : Ginggiva feels warm, pain (-), blood (-)

D. Assesment I
1. Recurrence mandibula salivary gland tumor T4N0Mx suspect adenoid
cystic carcinoma dd pleomorphic adenoma dd polymorphous low-
grade carcinoma
2. Anemia (Clinical)
3. Hepatomegaly

E. Plan I
1. Check blood routine
2. Chest X-ray
3. CT Scan Jaw + Neck
4. USG abdomen
5. Excision Biopsy
6. Consult oncology surgery