ADENOID

CYSTIC CARCINOMA, LEFT SUBLIGUAL GLAND HEMI MANDIBULECTOMY

 Name:

MR. X (not his real name) Age: 52y/o Sex: MALE Civil Status: MARRIED Religion: CATHOLIC Address: SAN FERNANDO, LA UNION

 Chief

Complaint: SUBMANDIBULAR PAIN

Diagnosis:

ADENIOD CYSTIC CARCINOMA, LEFT SUBLIGUAL GLAND HEMI MANDIBULECTOMY

 Mr.

X is a 52y/o, male, he was born on the 4th day of April 1959, born and grew up at San Fernando, La Union. There were 9 of them siblings, 2 boys and 7 girls, and his the 4th among them.

 He

has no medical history of any kind of illness from both sides of his parents. However, his cousin in his *** side has acquired breast cancer due to lifestyle. Mr. Xs first wife died because of hypertension and hepatitis condition, they were blessed of 3 children.

 On

year 2005, Mr. X got married for the second time to Mrs. X and blessed with 1 child. Mr. X supports his family as a famer and it is also his source of income. He spends most of his time under the sun for planting. Mr. Xs diet is more on vegetables and fish, they also prepares meat as their

dish once or twice a week. He prefers additional table spices ( e.g soy sauce, patis, vinegar, pepper, chili ). Mr. X is fun of smoking before, he can consumed 1 pack of cigarette per day or more for 20 years before he acquired such disease.

he also drinks beverages occasionally, he stopped smoking after his first surgery.

ERIC

ERICKSON

ADULTHOOD (25-65y/o)

GENERATIVITY vs. STAGNATION

POSITIVE RESOLUTION

CREATIVITY, PRODUCTIVITY, CONCERN FOR OTHERS

NEGATIVE RESOLUTION

SELF-INDULGENCE, SELFCONCERN, LACK OF INTEREST AND COMMITMENT

 HAVIGHURSTS

AGE PERIOD and DEVELOPMENTAL TASKS

LATER MATURITY Adjusting to decreasing physical strength and health Adjusting to retirement and reduce income Adjusting to death of spouse Establishing explicit affiliation

with ones age group Meeting social and civil obligation Establishing satisfactory physical living arrangement

 PAST

HISTORY

Patient had an operation 2

years ago which was done to remove a mass on his submandibular area. He was discharged, improve after completing his treatment and antibiotics.

 2 months PTC, pt. complained

of pain on his left submandibular area that radiates to the whole head. No consultation was done and pt. self medicated with mefenamic acid and amoxicillin, but these afforded minimal relief of symptoms. A few days PTC, the pt. can no longer tolerate the pain on his

submandibular area. He sought consult in OPD in BCGH and was admitted. Year 2009, pt underwent surgery to remove his submandibular area. Previous accident and trauma No history of cancer, DM, HPN, CAD, asthma and ulcer.

 PRESENT

HISTORY

The

pt. present condition is submandibular pain

 Mr.

X was brought to Baguio General Hospitals Out Patient Department accompanied by his wife on the 10th day of September,2011.

 Baguio

General Hospital is a

 ASSESSMENT

Masakit kapag kumakain ako

as stated With facial grimace noted when ingesting food With difficulty mastication noted With difficulty swallowing noted

 With asymmetric facial contour

on the left mandibular region With dental carries noted With pink buccal mucosa With swollen sublingual tongue noted No discharges noted With poor appetite

 NURSING

DIAGNOSIS

ALTERED NUTRITION: LESS THAN

BODY REQUIREMENT r/t DIFFICULTY MASTICATION secondary to SUBLINGUAL CARCINOMA

 OUTCOME

IDENTIFICATION

AFTER

 IMPLEMENTATION

ASSESSED GENERAL STATUS

OBSERVED PT. APPETITE

MONITORED BASELINE WEIGHT PROVIDED SMALL FREQUENT

FEEDING

 RATIONALE

TO