Case Report

(1)

Case Report

指導老師：林立民教授陳玉昆主任王文岑醫師陳靜怡醫師報告者：Intern F 組劉旻育伍芝瑩田序靜林俊男廖秉輝

(2)

General Data

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Name : 王ＯＯ

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Gender : male

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Age : 68

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Native : 台灣

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Occupation : 司機

Chief Complaint

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Swelling over left cheek

(3)

Present Illness

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This 68 y/o male patient suffered from above

episode for 1 week. He felt pain and swelling over left buccal mucosa. So, he came to our OPD for further treatment.

According to her daughter, two weeks ago, he went to 大同 hospital due to

osteophyte and fever. He

also had dry cough during

this period.

(4)

Past History

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Past Medical History

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NP

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Past Dental History

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Extraction

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Prosthesis

(5)

Personal History

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Oral habits

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Alcohol : (+)

1~2 bottle / day for 50 years

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Betel quid : (+)

15 grains / day for 50 years

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Cigarette : (+)

1 pack / day for 50 years

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Other habits : (-)

(6)

Intraoral Examination

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A firm, rough surface swelling mass

measuring about 4x 3.5 cm, was found over left cheek

mucosa, extending from left mouth angle to molar region.

(7)

Physical Examination

z Pain (+)

z Swallowing pain (+)

z Tenderness (+)

z Induration (+)

z Fever or local heat (-)

z Lymphadenopathy (+) :

Over left submandibular and neck region

(8)

Radiographic Examination

z No bony involvement from the lesion is noticed.

z Condyle : NP

z Sinus : NP

z Dental findings :

z Missing teeth : 11,15,17,18,21,24,25,31,32,36,37,38,41,46

z Residual root : 14

z Prosthesis : 23XX26, 42XXX333435X, 4445X

z PDL widening : 12,13,23,34,43,44,45

z Periodontal condition : moderate

(9)

Inflammation or Neoplasm

z Fever or local heat (-) / (+)

z Lymphadenopathy (+)

z Induration (+)

z Short duration (2 weeks)

Inflammation or Neoplasm

(10)

Benign or Malignant

z Pain (+)

z Tenderness (+)

z Induration (+)

z Lymphadenopathy (+)

z Poorly-defined margin

Malignant

(11)

1. Squamous cell carcinoma

2. Metastatic malignancy

Working Diagnosis

- Neoplasm

(12)

Working Diagnosis

- Inflammation

1. Major aphthous ulcer

(immunocompromised)

2. Tuberculosis

3. Necrotizing ulcerative mucositis

4. Necrotizing sialometaplasia

(13)

Working Diagnosis

z Squamous cell carcinoma

z Major aphthous ulcer

(immunocompromised)

z Tuberculosis

z Necrotizing ulcerative mucositis

z Necrotizing sialometaplasia

z Metastatic malignancy

(14)

Squamous Cell Carcinoma

(Early Lesion)

Our case SCC Site Left cheek Tongue

Gender Male Male

Age 68 Older (>40)

Frequency 94% of all oral malignancies Symptom Pain PainlessÆ pain Surface Rough Rough Consistency Firm Firm

Mobility Fixed Fixed

(15)

Squamous Cell Carcinoma

(Early Lesion)

Our case SCC

Rolled border

_ +/-

Shape Irregular Irregular Color Red and

white

Red and white Tenderness + +

LAP + +

Induration + +

Ulcer + +

(16)

Major Aphthous Ulcer

(Immunocompromised)

Our case MAU Gender Male

Age 68 Puberty +

Frequency common

Symptom Pain, swelling Pain, no swelling Size 4 X 3.5 cm 0.5 – 3.0cm

(or larger)

Site Left cheek Movable mucosa Surface Rough Usually smooth

(17)

Our case MAU

Color Red and white Red and white (necrotic)

Shape Irregular regular Consistency Firm soft

Mobility Fixed movable Tenderness + +

LAP + -/+ (HIV)

Induration + -

Major Aphthous Ulcer

(Immunocompromised)

(18)

Tuberculosis

Our case Tuberculosis Gender Male

Age 68 >40 y/o

Frequency 0.5 - 1.5%

Color Red and white Red and white Shape Irregular Irregular

Tenderness + +

LAP + +

Induration + - Symptom Pain,

swelling

Pain/Painless ulcer

Site Left cheek Tongue, palate, lip

Surface Rough Rough

(19)

Necrotizing Ulcerative Mucositis

Our case NUM Gender Male

Frequency Uncommon

LAP + +

Age 68 Young

Site Left cheek Initial lesion: NUG Late lesion: NUM

Consistency Firm soft

Color Red and white NUG: Red

NUM: Red and white Symptom Pain, swelling Pain

Tenderness + -

Induration + -

(20)

Necrotizing Sialometaplasia

Our case Necrotizing Sialometaplasia Gender Male Male

Age 68 46

Frequency of occurrence

Uncommon (potential predisposing factor )

Site Left cheek 75% in posterior palate Surface Rough Early lesion : swelling

Late lesion : craterlike ulcer Symptom Pain, swelling Pain or paresthesia

Size 4 X 3.5 cm <1cm to >5cm

Induration + -

Consistency Firm Soft

Tenderness + -

LAP + -

(21)

Metastatic Malignancies

Our case Metastatic malignancies Gender Male Male

Age 68 Middle ~ older adults

Frequency 1%

Site Left cheek Gingiva(>50%) Surface Rough, ulceration Ulceration

Shape Irregular Nodular mass

(22)

Clinical Impression

Squamous Cell Carcinoma

Tuberculosis

(23)

z 9/11 check biopsy outcome in OS dept.

z Incisional biopsy was performed over left buccal mucosa.

Biopsy

(24)

z 9/11 Refer to 胸腔內科 for chest x-ray

and further treatment.

(25)

Chest PA View Findings

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Image findings :

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The heart size is not enlarged.

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The aorta is dilated.

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Both lungs reveal multiple

nodules and interstitial pattern.

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The hila and mediastinum are unremarkable.

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The thoracic cage is intact.

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There are spurs of the T-,L- spine.

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Scoliosis of the T-spine is noted.

(26)

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Impression :

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Atherosclerosis of the dilated thoracic aorta.

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Interstitial lung disease of both lungs. Metastatic or infectious/ inflammatory

diseases should be included in differential diagnosis.

CT of chest is suggested.

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Spondylosis of the T-,L-

spine and mild thoracic

scoliosis.

(27)

Hematological Examination

項目結果值參考標準值單位檢體收集時間

WBC 7.06 4.0-10.0 *1000/ul Blood 95/9/11-17:02 RBC 4.69 4.5-6.0 *10⁶/ul Blood 95/9/11-17:02

Hgb 11.8 13-17 g/dl Blood 95/9/11-17:02

Hct 39.1 40-53 % Blood 95/9/11-17:02

MCV 83.4 79.0-101.0 fl Blood 95/9/11-17:02

MCH 25.2 26.0-35.0 Pg Blood 95/9/11-17:02

MCHC 30.2 31.0-37.0 g/dl Blood 95/9/11-17:02

PLT 261 130.0-500.0 *1000/ul Blood 95/9/11-17:02 RDW-CV 15.8 11.5-14.5 % Blood 95/9/11-17:02 RDW-SD 48.0 36.0-46.0 fl Blood 95/9/11-17:02