HLTH
Seyer, Nick Male, 58 y.o. Allergies: None Pt. Location: RM 832
Code: FULL Physician: H. Brown
Isolation: None Admit Date: 9/5
Patient Summary: The biopsy revealed a stage IV T2 N2b, HPV (human papilloma virus) positive, squamous cell carcinoma (SCC) of the right anterior tongue.
History: Onset of disease: Odynophagia 3 5–6 months Medical history: Hypertension, which he states is well controlled. Patient describes noticing a “pim- ple” on his tongue approximately 5–6 months ago. He noticed that this mass seemed to slowly
get worse and he began having significant pain with eating. He states this is especially true with spicy or acidic foods like salsa, hot sauce, or orange juice. He has noted an approximately 30-pound weight loss over 5–6 months. He never expected that cancer could be the cause. Medications at home: Metoprolol Tobacco use: Yes, 2 ppd; wife also smokes. Alcohol use: Yes, 1–2 drinks most nights of the week. Family history: What? Liver cancer. Who? Mother—died age 58.
Demographics: Marital status: Married Household members: Wife, age 52; son, age 18; two other sons are away at college—ages 19 and 22 Years education: Some college Language: English only Occupation: Contractor Hours of work: Variable but usually 5–6 days per week—starts as early as 6:30 and works often until after 6 pm Ethnicity: Caucasian Religious affiliation: Catholic
Admitting History/Physical: Chief complaint: Tongue pain for several months that has progressively gotten worse. Weight loss due to pain with eating.
Vital Signs: Temp: 98.3°F Pulse: 88 Resp rate: 13 BP: 132/92 Height: 6’3” Weight: 198 lbs
Heart: Unremarkable HEENT: Positive for hearing loss and sore throat. Negative for ear pain, nosebleeds, congestion, hoarse voice,
rhinorrhea, and sinus pain. There is no tinnitus or ear discharge. Eyes: Sunken; sclera clear without evidence of tears Ears: Clear Nose: Dry mucous membranes Throat: Dry mucous membranes, no inflammation Genitalia: Unremarkable Rectal: Prostate normal; stool hematest negative Neurologic: Alert, oriented 3 3 Extremities: Joints appear prominent with evidence of some muscle wasting. No edema. Skin: Warm, dry Chest/lungs: Clear to auscultation and percussion Abdomen: Negative for pain or tenderness.
Seyer, Nick Male, 58 y.o. Allergies: None Pt. Location: RM 832
Code: FULL Physician: H. Brown
Isolation: None Admit Date: 9/5
Orders: Surgery consult to evaluate for possible surgical resection. Radiation oncologist and medical oncologists consulted to evaluate for postoperative external beam radiation therapy and chemotherapy.
R. Brown MD
Nursing Assessment 9/5 Abdominal appearance (concave, flat, rounded, obese, distended) rounded Palpation of abdomen (soft, rigid, firm, masses, tense) soft Bowel function (continent, incontinent, flatulence, no stool) continent Bowel sounds (P5present, AB5absent, hypo, hyper)
RUQ P
LUQ P
RLQ P
LLQ P
Stool color brown
Stool consistency soft
Tubes/ostomies N/A
Genitourinary
Urinary continence yes
Urine source clean catch
Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, blue, tea) clear, yellow
Integumentary
Skin color pale
Skin temperature (DI5diaphoretic, W5warm, dry, CL5cool, CLM5clammy, CD15cold, M=moist, H5hot)
W
Skin turgor (good, fair, poor, TENT5tenting) fair
Skin condition (intact, EC5ecchymosis, A5abrasions, P5petechiae, R5rash, W5weep- ing, S5sloughing, D5dryness, EX5excoriated, T5tears, SE5subcutaneous emphysema, B=blisters, V5vesicles, N=necrosis)
D
Mucous membranes (intact, EC5ecchymosis, A5abrasions, P5petechiae, R5rash, W=weeping, S5sloughing, D5dryness, EX5excoriated, T5tears, SE5subcutaneous em- physema, B5blisters, V5vesicles, N5necrosis)
D
Other components of Braden score: special bed, sensory pressure, moisture, activity, friction/shear (..185no risk, 15–165low risk, 13–145moderate risk,#125high risk)
activity, 16
Seyer, Nick Male, 58 y.o. Allergies: None Pt. Location: RM 832
Code: FULL Physician: H. Brown
Isolation: None Admit Date: 9/5
Nutrition: General: Mr. Seyer noted decreased intake prior to admission. He states this is mainly related to tongue pain, but also thinks his appetite is poor, and he feels full quickly when eating. He does not have any problem swallowing. He is not having nausea or vomiting.
Usual dietary intake: AM: Used to eat eggs, bacon, toast, and juice every morning, but for at least the past month he has eaten only eggs or oatmeal instead. He states that the toast is too dry and difficult to chew and the bacon isn’t appealing. Juice causes significant discomfort. Lunch: Previously, ate cold lunch packed for the work site. This included sandwich, cold meat or other leftovers from previous dinner, fruit, cookies, and tea. Lately he is drinking Ensure Active High Protein or a smoothie from McDonald’s. He states drinking is easier than eating. Sometimes he doesn’t eat lunch at all due to pain. Dinner: He used to eat large portions of meat with a starch, vegetables, and salad. He usually drinks 2–3 beers after dinner. Lately he has found meat and salad difficult to eat. He prefers soups, mashed potatoes, etc. He is still drinking beer after dinner.
24-hour recall: AM: 1 packet of instant oatmeal; sips of coffee Lunch: 6 oz chicken noodle soup with 2–4 crackers Dinner: Macaroni and cheese—homemade, ½ c Bedtime: 1 scoop of chocolate ice cream
Food allergies/intolerances/aversions: None Previous nutrition therapy? No Food purchase/preparation: Wife Vit/min intake: None. Used to take a multivitamin, but hasn’t in years.
Seyer, Nick Male, 58 y.o. Allergies: None Pt. Location: RM 832
Code: FULL Physician: H. Brown
Isolation: None Admit Date: 9/5
Laboratory Results
Ref. Range 9/5 0832 9/11 0832 Chemistry Sodium (mEq/L) 136–145 137 136
Potassium (mEq/L) 3.5–5.1 3.8 3.6
Chloride (mEq/L) 98–107 101 99
Carbon dioxide (CO2, mEq/L) 23–29 26 25
BUN (mg/dL) 6–20 9 10
Creatinine serum (mg/dL) 0.6–1.1 F 0.9–1.3 M
0.9 0.9
Glucose (mg/dL) 70–99 71 98
Phosphate, inorganic (mg/dL) 2.2–4.6 3.2
Magnesium (mg/dL) 1.5–2.4 1.8 1.8
Calcium (mg/dL) 8.6–10.2 9.1 9.4
Bilirubin, direct (mg/dL) ,0.3 0.2 0.3 ! Protein, total (g/dL) 6–7.8 5.7 ! 5.7 ! Albumin (g/dL) 3.5–5.5 3.1 ! 3.0 ! Prealbumin (mg/dL) 18–35 15 ! 12 ! Ammonia (NH3, µg/L) 6–47 11 21
Alkaline phosphatase (U/L) 30–120 101 99
ALT (U/L) 4–36 21 33
AST (U/L) 0–35 32 27
CPK (IU/L) 30–135 F 55–170 M
162 145
Lactate dehydrogenase (U/L) 208–378 300 290
Cholesterol (mg/dL) ,200 180 170
HDL-C (mg/dL) .59 F, .50 M 47 ! LDL (mg/dL) ,130 129
LDL/HDL ratio ,3.22 F ,3.55 M
2.74
Triglycerides (mg/dL) 35–135 F 40–160 M
158
Coagulation (Coag)
PT (sec) 11–13 12 12.8
Hematology
WBC (3103/mm3) 3.9–10.7 5.2 6.9
RBC (3106/mm3) 4.2–5.4 F 4.5–6.2 M
4.2 ! 4.3 !
Hemoglobin (Hgb, g/dL) 12–16 F 14–17 M
13.5 ! 13.9 !
Hematocrit (Hct, %) 37–47 F 41–51 M
38 ! 38 !
Mean cell volume (µm3) 80–96 90 86
Mean cell Hgb (pg) 28–32 32.4 ! 32.3 !
(continued)
Seyer, Nick Male, 58 y.o. Allergies: None Pt. Location: RM 832
Code: FULL Physician: H. Brown
Isolation: None Admit Date: 9/5
Ref. Range 9/5 0832 9/11 0832 Mean cell Hgb content (g/dL) 32–36 35.5 36.5 ! Platelet count (×103/mm3) 150–350 250 232
Ferritin (mg/mL) 20–120 F 20–300 M
220 208
Hematology, Manual Diff
Neutrophil (%) 40–70 55 65
Lymphocyte (%) 22–44 25 35
Monocyte (%) 0–7 4 5
Eosinophil (%) 0–5 0.5 0
Segs (%) 0–60 55 60
Bands (%) 0–10 4 3
Note: Values and units of measurement listed in these tables are derived from several resources. Substantial variation exists in the ranges quoted as “normal” and these may vary depending on the assay used by different laboratories.
Intake/Output
Date 9/11 0701–9/12 0700 Time 0701–1500 1501–2300 2301–0700 Daily total
IN
tube feeding formula 600 535 600 1735 tube feeding flush 50 50 50 150 (mL/kg/hr) (0.90) (0.81) (0.90) (0.87)
I.V. 800 800 800 2400 (mL/kg/hr) (1.11) (1.11) (1.11) (1.11)
I.V. piggyback
TPN
Total intake 1450 1385 1450 4285 (mL/kg) (16.11) (15.39) (16.11) (47.61)
OUT
Urine 1100 1700 900 3700 (mL/kg/hr) (1.53) (2.36) (1.25) (1.71)
Emesis output
Other
Stool 0 0 300 300 Total output 1100 1700 1200 4000 (mL/kg) (12.22) (18.89) (13.33) (44.44)
Net I/O 1350 2315 1250 1285 Net since admission (9/5) 1400 185 1335 1335
Laboratory Results (continued)