M-43-hudson,t
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Jan 9, 2024
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Uploaded by Chief_Neutron_Sheep5
Radiation Oncology Followup Note
Patient Name Joel Flores
PCP Sherman Lloyd, MD
Date of Exam November 16
2023
Age/Sex 57/M
ID
#
: M-43
DIAGNOSIS Squamous cell carcinoma, floor of mouth, stage IVA (T4aN2M0).
INTERVAL HISTORY Compared to his last visit 4 months ago there has been no change. Mr. Flores
continues to feel well. He is able to swallow liquefied foods. Dysgeusia continues to resolve but oral
dryness persists.
PHYSICAL EXAMINATION He looks well. Weight is 179 pounds (increased from 174 pounds on his last
visit), blood pressure 170/90, heart rate 72, and temperature 96.9. HEENT AND NECK: Patient is blind. No
scleral icterus. No adenopathy in the neck or clavicular region. There are obvious persistent defects from
his hemimandibulectomy and previous radiation therapy. He has evidence of a partial glossectomy and
graft. Thickened, tenacious mucus is present. There is no palpable tumor in the oral tongue, floor of
mouth, tonsillar bed, or base of tongue. Endoscopy to the right nasion: No evidence of tumor in the
nasopharynx, base of tongue, vallecula, supraglottic or glottic larynx. Vocal folds adduct normally with
phonation. lungs Clear to auscultation. cardiovascular Regular rate and rhythm without murmurs.
abdomen No masses. extremities No edema. neurologic Cranial nerves intact, as are mentation and
motor power.
IMPRESSION The patient is a 57-year-old blind man with stage IVA (T4aN2M0) squamous cell carcinoma
of the floor of the mouth, who currently has no evidence of disease. He has persistent sequelae of his
therapy and his cancer, but he is doing quite well.
PLAN He will return to the radiation oncology clinic in 3 months for followup evaluation, and he will also
follow up in the ENT clinic. I have ordered a TSH as well as CT of the head and neck in routine followup.
L. (Lonnie) Willem Erwin, MD
Radiation Oncology
LE:THG
D: November 16
2023
T: November 17
2023
Please send a copy of this report to Leah Pittfield, MD, Otorhinolaryngology and Sherman Loyd, MD,
Internal Medicine
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