History

62 yo M c/o hoarseness that has been ongoing for 3 months and getting worst. Hoarseness is
present at all times without any pain. Nothing improved or makes the hoareness go away. Has a flu
like illness 4 weeks ago of sore throat and running nose, which has resolved. Patient c/o heart burn,
weight loss of 10 lbs in 3 months and poor appetite. ALso feels a lump in his throat and "feeling hot".
No chills, SOB, chest pain is noted.
ROS: negative except as above and heartburn.
Allergies: none
Medication: none
PMH: none High cholesterol
PSH: none
FH: dad died from lung cancer and mom has thyroid problems.
SH: Lives by himself. Retired teacher of 30 years. smokes 1 PPD x 30 years. Drinks 3 glasses daily; 0/4
CAGE.

Physical

Patient is comfortable
Vitals: WNL except T 99.9F
HEENT: EOMI, no excudate from throat. Nose, mouth and pharynx WNL
Neck: No LAD noted.
Chest: S1/S2 present, RRR, no m/g/r
Lungs: CTA BL, nontender
Abd: soft, nontender, nondistended

Diagnosis

Diagnosis 1 Lung cancer (laryngitis)

History Findings (s) Physical Finding (s)

Smoking history

Weight loss

Hx of flu 4 weeks ago

Diagnosis 2 Laryngeal cancer

History Findings (s) Physical Finding (s)

Smoking and drinking history Low grade fever

Weight loss

Worsening hoarseness

Advanced age
Diagnosis 3 GERD/Baretts esophagus
History Findings (s) Physical Finding (s)

Smoking and drinking history

Weight loss

burning sensation mid epigastric

Diagnostic study/studies
CBC

CXR

Laryngoscopy

CT -chest and neck

U/S - neck

Stomach pH monitor

ESR