pooja final ppt

8/3/2019 Pooja Final Ppt

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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


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)



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)



feed-260cc

25/6/11 step up + oral sips

actual requirements for the patient has been met


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(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


5.30 pm 260cc formula feed


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


(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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pooja final ppt

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