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2020/7/13 鄒O東7927904
Dx: Right upper buccogingival SCC, cT4aN0M0, cstage…
2020/7/13 鄒O東7927904
Dx: Right upper buccogingival SCC, cT4aN0M0, cstage IVA
Chief complaint
Unhealed ulcer at right upper gingiva noted for 1 year, enlargement of the lesion noted in the recent 2 weeks
Clinical approach
Medical history:
- HTN under medical control
- DM under medical control
- HBV carrier
- Anal fistula and hemorrhoid s/p OP in 2004 and 2005
Present illness: A ulceration noted at right upper gingiva with poor healing noted for 1 year, rapid enlargement noted in the recent 2 weeks. Went to 關渡 for help and was then transfered to VGHTPE for r/o malignancy.
A(-)B(-)C(+: 25 year, 1ppd, quit for 15 years)
Current symptoms and sign:
- Mass noted at right upper gingiva
- Pain noted at the mass lesion noted
Physical examination
Extraoral examination
Inspection: Symmetric appearance.
MMO:35mm, no trismus or deviation noted.
Palpation: 1 palpable lymph node at right level Ib, Freely movable
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Radiographic examination
Panoramic film:
- Missing of 3738, 4748
- Ill fitting prosthesis at 16x14
- Increased soft tissue volume noted at right upper buccal region
Face CT scan:
- A mass lesion at right upper gingiva with destruction of right maxilla
- An enlarged lymph node in size about 1.7cm at right level Ib
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Whole body bone scan:
- Increased MDP uptake at right upper jaw, compatible with tumor invasion
Incisional biopsy
Squamous cell carcinoma, moderately differentiated
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