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CASE STUDY
ORAL CANCER
Submitted By:-
POOJA THAKKAR
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Patient profile
Name-NagammaAge-60 years
Sex-female
Doctor-NSG
Diagnosis-CA of tongue
Length of hospital
Family size-6 adult, 2 children
Occupation-cateringFood habit-no vegetarian
Ethnic background-telgu
Residence-Mumbai (vile Parle)
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Anthropometry measurements
Height-143cmPreoperational weight-46 kg
Post operation weight-45 kg
Ideal body weight-44kg
Body mass index-22.5kg meter square
Subjective global assessment D GRADE
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Clinical findings
Case of ulcerative proliferative growth on the right lateralborder since two months, along with pain.
History of dysphagia can tolerate liquid diet.
History of haemetasis
History of tobacco chewing for more than 30 years, 5 to 6
times daily.
And consuming tea 6-7 times a day
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Investigation
Biopsy of tongue-lesion of squamous cell (CA)USG-appearance of suggestive neoplasm along middle and
posterior third right lateral border of oral tongue measuring
3cm *1.6cm*2.6cm. No involvement of basal tongue few
enlarge lymph node noted in deep cervical region bilaterallyleft side 2cm*0.8*1.6.
Microscopy- all tissue processed section shows tumor tissue
with feature of invasive moderately.
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Name dosage Justification
Inj.Augmentin Iv 12 hourly Bacterial infection
Inj.flagyl Iv 8 hourly Antibacterial
Inj.tramdol Iv 8 hourly Painkiller
Inj.Rantac Iv 8 hourly Antidiarrhoeal
Inj.Deca Iv 12 hourly Steroid injection
1PintRL
1PintDNS
1PintNS
For maintaining blood
volume
Syrup combiflam 10ml-0-10ml Painkiller
Syrup tonoferon 10ml-0-10ml Iron supplement
Syrup regamil 10ml-0-10ml Multivitamin
Medication (21/6/11-27/6/11)
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Review of literature
Tongue cancer is a common type of cancer which is calledsquamous cell carcinoma. The tumor is usually is located on the
side lateral border of the oral tongue. It is usually ulcerated and
is grayish pink to red colour. It will bleed easily if beaten or
touched. Larger cancers may indeed have some effect on speech
and swallowing. Smoking alcohol, chewing tobacco is known to
contribute to the formation of cancer. In case of oral cancer it can
be treated by just removal of primary tumor in the tongue. As the
size of the tumor increases, the possibility of spreading through
lymph vessels to the lymph nodes of the tongue increases.
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Causes of tongue cancer
Tobacco-use accounts for most oral cancer. Smoking
cigarettes, cigars, chewing tobacco and other products. The
risk of cancer is even higher for those who consume tobacco
and also drink. The risk increases with the amount of alcohol
the person consumes. People who have had head, neck cancerare at higher risk of developing another primary head and
neck cancer on smoking
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Signs and symptoms of tongue cancer
Patches inside the mouth or on the lips that are white
patches, a mixture red and white or red patches
White patches (leukoplakia) are most common. White
patches sometimes become malignant.
Mixed red and white patches (erythroleukoplakia) are
more likely than white patches to become malignant
Red patches(erythroplakia) are bright coloured,smooth areas that become malignant
A sore on lips or in the mouth that wont heal, leads to
bleeding in the mouth, difficulty in swallowing and lump
in the neck
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Diagnosis
Oral cancers can be diagnosed by some physical examinationsuch as red and white patches, lumps, swelling or other
problem in the mouth or the throat. The biopsy is also done
with local generalized anesthesia. A biopsy is the sure way to
know if the abnormal area is cancerous.
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Treatment
If the biopsy shows cancer is present, the stage of the diseaseis evaluated and the treatment is correctively taken. The stage
is based on the size of the tumor and the areas it has been
spread to. The surgery hemiglossectomy involves removal of
a part of a tongue and its adjacent tissues.
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Name Normal value 6/6/11 22/6/11
WBC 4-11*103/ul 4.7*103/ul 14.1*103/ul
Lymphocyte 1.4-3*103/ul 2.0*103/ul 1.9*103/ul
Monocyte 0.1-0.7*103/ul 1.3*103/ul 0.3*103/ul
Granulocyte 2.8-5.8*103/ul 1.4*103/ul 11.9*103/ulLymphocyte % 25-45% 42.3% 13.5%
Monocyte % 4-7% 29.9% 2.1%
Granulocyte % 45-70% 27.8% 84.4%
RBC 3.50-5.60*106/ul 4.47*106/ul 3.64*106/ul
Hgb 11-18g/d 11.4g/d 10.5g/d
HCT 32-54% 38% 33.1%
MCV 79-101 fl 85fl 90.9fl
MCH 26-36pg 25.5pg 28.8pg
MCHC 31-37g/dl 30g/dl 31.7g/dl
RDW 11.5-14.5% 14% 11.7%
PLT 120-500*103/ul 27*103/ul 226*103/ul
PCT 0.130-0.280% 0.2% 0.160%
MPV 9-17 fl 7.8 fl 7.1flPDW 11.5-14.5 fl 7 fl 11.9fl
FBS 70-110 mg/dl 104 mg/dl 103mg/dl
PLBS
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Time Menu Amount Energy
(Kcal)
CHO
(gms)
Prtn
(gms)
Fat
(gms)
Na+
mEq
K+
mEq
9 am Cutting tea
Sugar
pav
2tsp
2 nos
21
40
200
1.32
10
40
0.96
----
0.75
----
21.9 42
2pm Rice
DalRoti
60 gms
15 gms60 gms
200
50200
42
8.542
3.6
3.55
1
0.251
4.8
412
40.8
197189.2
4 pm Tea
Sugar 2tsp
21
40
1.32
10
0.96 0.75 21.9 42
9.30 pm Dal
/fish/mutto
n
/chicken
Rice
roti
15 gms
60 gms
60 gms
50
200
200
8.5
42
42
3.5
3.6
5
0.25
1
1
4
4.8
12
197
40.8
189.7
Total oil 30 gms 270 30
TOTAL 1492 247.6 26.12 36 3.7 24
Home recall of the patient (a month ago)
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Medical nutritional therapy
Objective-
To give neutropenic diet
Avoid further catabolism
Avoid reduction in lean body mass
Meet additional immune nutrient requirements
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energyan estimate of 45-50Kcal per present body weight is
given as cancer is a stressful condition
carbohydrateabout 60% of energy is recommended to comefrom carbohydrates so as to conserve lean body mass and to
prevent protein breakdown.energy from mainly simple carbs
should be avoided
Fatsabout 20-30% of energy should come from fats which is
calorically dense source of energy and also helps in absorption ofvitamins and minerals SFA:MUFA:PUFA ratio has to be
maintained ,not more than 40% of PUFA should be given as it
has immunosuppressive effect
Proteinabout 1.5-2 gms per present body weight is given tomaintain nitrogen balance, avoid muscle proteolysis and for
tissue growth.
Vitamins and mineralsincrease quantity of vitamins and
minerals are needed in high amount for their wound healing and
antioxidant property .Given requirement by FDA
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Vitamin A 3300 IU
Vitamin D 200 IU
Vitamin E 10 IU
Vitamin K 150 ug
Vitamin C 200mg
Vitamin B1 6mgVitamin B2 3.6mg
Vitamin B3 40mg
Vitamin B6 6mg
Vitamin B12 5ugZinc 2500-4000 ug
Copper 300-500ug
Chromium 10-15 ug
Manganese 60-100 ug
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Glutamine 60mg/d (0.6g/PBW)
Arginine 9gm
Omega3 1.8-2gm/d
Fluid need -1ml/kcal of energy
Immunonutrient- since patient is non affording enough sourceof milk and egg was given to meet adequate amount of
glutamine & arginine.Also fish cod liver oil was given to meet
omega 3 requiremnt.
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Hospital diet
20/6/11-surgery
21/6/11-NBM
22/6/11-referred for diet
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Energy (Kcal) 2250 (50Kcal/PBW)
CHO (gms) 303 (54%)
Prtn (gms) 90 (2gm/PBW)
Fat (gms) 75 (35%)
Fluid (ml) 2125
Requirement of patient
Energy=PBW*50kcal45*50=2250kcals
Protein=2gm/PBW2*45=90gm360kcal16%
Fats=35% 787kcals75gms
CHO54%1215303gms
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Time Menu
12.30 pm 25cc kanji/soup
2.30 pm 50cc kanji/soup
4.30 pm 75cc kanji/soup6.30 pm 100cc kanji/soup +1tsp PHP
8.30 pm 125cc kanji/soup +2tsp PHP
10.30 pm 100cc milk + 3 tsp PHP
22/6/11 TEST FEED
(PHP-pentasureHP)
Urine output: 820ml
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Energy-1740 Kcal(39Kcal/PBW)
Na+ 49mEq Total volume of feed-1350cc
CHO-180gm (41%) K+ 56mEq Volume from formula
feed-1050
PRTN-
62.7gm(1.5gm/PBW)
NNC-1490Kcal No of formula feeds-5
FAT-67gm (34%) Cal:N2 174:1 Volume per formula
feed-210cc
23/6/11 -24/6/11FORMULA FEED
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name Exchange Energy
(Kcal)
CHO
(gms)
Prtn
(gms)
Fat
(gms)
Na+
mEq
K+
mEq
Rice 3(90gms) 300 63 5.4 1.5 7.2 61.2
Dal (15gms) 50 8.5 3.5 0.25 4.2 197
Milk 9(900ml) 630 39.6 28.8 22.5 657 1260
wholeEgg
2 170 13 13 342 322
Vegetable
pulp
(vegA)
4 100 24 108
Fish Cod
liver Oil
30gm 270 30
Sugar 30gm 120 30
PHP 30gm 100 15 12 120 240
Total 1740 180 62.7 67.25 49 56
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Time Menu
9.30 am 150cc milk+ 3tsp PHP
11.30 am 210cc formula feed +1tsp zincovit syrup
1.30pm 210cc formula feed
3.30 pm 210cc formula feed +1tsp zincovit syrup
5.30 pm 210cc formula feed
7.30 pm 210cc formula feed +1tsp zincovit syrup
9.30 pm 150cc milk+ 3tsp PHP
23/6/11 -24/6/11
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Energy-1740 Kcal(39
Kcal/PBW)
Na+ 49mEq Total volume of feed-
1350ccCHO-180gm (41%) K+ 56mEq volume of formula
feed-1050cc
PRTN-
62.7gm(1.5gm/PBW)
NNC-1490Kcal No of formula feeds-5
FAT-67gm (34%) Cal:N2 174:1 Volume per formula
feed-210cc
Observation
Following days no aspiration was seen using Ryles tube and after
2 days patient was started on oral sips.
Average calorie of 2 days of hospital recall
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Energy-2225 Kcal(50
Kcal/PBW)
Na+ 62mEq Total volume of feed-
1600cc
CHO-231gm (41%) K+ 72mEq volume of formulafeed-1300cc
PRTN-
84gm(1.9gm/PBW)
NNC-1889Kcal No of formula feeds-5
FAT-87gm (35%) Cal:N2 171:1 Volume per formula
feed-260cc
25/6/11 step up + oral sips
actual requirements for the patient has been met
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name Exchange Energy
(Kcal)
CHO
(gms)
Prtn
(gms)
Fat
(gms)
Na+
mEq
K+
mEq
Rice 4(120gm) 400 84 7.2 2 9.6 81.6
Dal 1(30gm) 100 17 7 0.5 8.4 394
Milk 10(1000m
l)
700 44 32 25 730 1400
whole
Egg
3 255 19.5 19.5 513 483
Vegetable
pulp
4 100 24 108
Fish cod
liver Oil
40gm 360 40
Sugar 40gm 160 40
PHP 45gm 150 22.5 18 180 360
Total 2225 231 84 87 62 72
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Time Menu
9.30 am 150cc milk+ 4 tsp PHP
11.30 am 260cc formula feed +1tsp zincovit syrup
1.30pm 260cc formula feed
3.30 pm 260cc formula feed +1tsp zincovit syrup
5.30 pm 260cc formula feed
7.30 pm 260cc formula feed +1tsp zincovit syrup
9.30 pm 150cc milk+ 4 tspPHP
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Time Menu
10.30 am 50 cc kanji/soup
12.30 pm 50 cc kanji/soup
2.30 pm 50 cc fruit juice without sugar
4.30 pm 50 cc coconut water
6.30 pm 50 cc soup/kanji
Oral sips started along with feed
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Observation
Patient had tolerated the RT and oral sips were also tolerated butcoconut water was not consumed
Care was taken that the soup was not hot and no straw was used
by the patient
26/6/11 Discharge diet
RT +oral clear liquid diet
Taking into consideration to meet the recommended vitamins,
mineral, fluids and immunonutrients through the diet by usingvarious sources
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Energy-2325 Kcal(51 Kcal/PBW) Na+ 76mEq Total amount of fluid from diet-
2650ml
CHO-251gm (43%) K+ 76mEq
PRTN-84gm(1.9gm/PBW) NNC-1989Kcal No of feeds-17
FAT-87gm (35%) Cal:N2 178:1
name Exchange Energy
(Kcal)
CHO
(gms)
Prtn
(gms)
Fat
(gms)
Na+
mEq
K+
mEq
Rice 4(120gm) 400 84 7.2 2 9.6 81.6
Dal 1(30gm) 100 17 7 0.5 8.4 394
Milk 10(1000ml) 700 44 32 25 730 1400
whole Egg 3no 255 19.5 19.5 513 483
Vegetable
pulp
4 100 24 108
Fish codliver Oil
40gm 360 40
Sugar 40gm 160 40
PHP 45gm 150 22.5 18 180 360
fruits 2no. 100 20 70 140
Total 2325 251 84 87 76 76
Time& menu Amount Ingredients
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g
7.30 am-raisin milkshake 200cc 200 ml milk+
Soaked and ground raisens+4 tsp of PHP
8.30 am 50 cc Boiled Water
9.30 am-orange juice 200 cc Sweet lime juice (2 no.) +
2 tsp sugar +1tsp zincovitsyp10.30am 50 cc Boiled Water
11.30am- eggnog 250 cc 200 ml Milk +1 egg +
2 tsp sugar+1capsule of cardepa
12.30pm(15gms rice) 50 cc Rice kanji
1.30pm khichdi 300 cc 15gm rice +
15gm dal +200 ml vegetable soup + 2 tsp fish oil+1tspzincovitsyp+ squeezed lime
2. 30 pm (15 gms rice ) 50 cc Rice kanji
3. 30 pm- egg nog 250 cc 200 ml milk +1 egg +2 tsp sugar+1capsule of cardepa
4. 30 pm (15gms rice ) 50 cc Rice kanji
5. 30 pm -raisin milkshake 200 cc 200 ml milk +Soaked and ground raisins 2 tsp sugar+2
tsp fish oil
6. 30 pm (15gms rice) 50 cc Rice kanji
7. 30 pm -rice&soup 300 cc 30 gm rice +200 m vegetable soup+2tsp fish oil
8. 30 pm 50 cc Boiled water
9.30 pm- khichdi 300 cc 15gm rice +15 gm dal+2 tsp fish oil+200cc vegetable
soup+1tsp zincovit syp+ squeezed lime10.30 pm 50 cc Boiled water
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Time Menu
10.30 am 50 cc kanji
12.30 pm 50 cc soup
2.30 pm 50 cc fruit juice without sugar
4.30 pm 50 cc coconut water
6.30 pm 50 cc soup
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follow up on 4/7/11 to remove sutures, and test soft diet intake
discharge diet of 2600cc -->energy 50kcal/PBW,prtn-1.9gm/PBW(highfluid,vitamin, mineral, immunonutrient)
Diet of1600cc --> energy 50kcal/PBW,PRTN 1.9gm/PBW + oral sipstartedopening of mouth is very little and sips are taken with help of a spoon
diet of 1350cc-->energy 39kcal/PBW,prtn1.5/PBW (2days)
WEIGHT LOSS OF 1 KG & URINE OUTPUT 700ML TO 1005 ML
CANCER OF TONGUE
NBM TEST FEED
PROGRESSION
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RECOMMENDATION
Keep the patient in upright position while feeding.
Keep the patient upright for 30mins after feedingIf the aspiration is more than 50% stop feeding and feed after 2 hrs
Keep the feed outside the refrigerator for 30 mins before giving the patient
Avoid raw foods for the patient
Consume boiled water
Maintain sanitized utensil for the patients food Store the prepared feed on table not more than 2 hrs, and refrigerated feed
for not more than 4 hrs.
Avoid consuming packet juice ,soups, puree, and nonveg soup
Maintain clean sanitary condition of the person feeding the patient as it may
lead to cross contamination.
Wash the RT with 20 ml distilled water after every feed
Restrict using food thickeners like potato, sweet potato, cornflour, arrowroot
through RT
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