Age: 61.0
Sex: M
Vaccine: COVID19
Symptoms: Radiotherapy, Radiotherapy to pharynx, Red blood cell count normal, Renal cyst, Scan with contrast abnormal
Clinical narrative: 3/17/21: Received the Johnson & Johnson Covid-19 Vaccine. I was a healthy, athletic man, a non-smoker, a non-drinker, and I don't chew tobacco. I had no prior symptoms, or known underlying conditions of a mouth, throat, tongue, or left neck lymph node problem before the Covid Vaccine. I had the second Shingrix shingles vaccine five weeks before the Covid shot. The Pharmacist said it was fine as long as the vaccines are one month apart. 4/27/21: I noticed a minor pain problem, in the lower, back, left area in my mouth, towards the back of my wisdom tooth. This occurred after I jabbed the back of my mouth with my toothbrush, when I was brushing my teeth. 5/25/21: Dental examination with my Dentist. I thought the problem in my mouth might be an abscessed tooth. He said there was not an abscess, but there was inflammation in the back, lower, left area of my mouth. He said it might be a minor bacterial infection from the trauma of my tooth brush, to monitor it, and if it doesn't heal, or if it gets worse, to see a Medical Doctor. 7/08/21: Examination with E.N.T. specialist. The problem in my mouth was gradually getting worse, a little more pain, especially when I brushed my teeth in the lower, back left side of my mouth. He noticed a small, abnormal growth in the left tonsil region, and also swelling of my left neck lymph node. He suspected malignancy. He prescribed a 1-week medication regiment of Clindamycin, (antibiotic), and oral Prednisone, (steroid). His objective was to rule out a possible bacterial infection. 7/29/21: Examination with E.N.T. specialist. The problem in my mouth was a little better 1-2 weeks after the bacteria treatment, but there was an area of local swelling in the problem area of my mouth. He thought it may be a localized abscess, but he was still suspicious of malignancy, and he ordered a CT scan, with contrast. 8/12/21: Examination with E.N.T. specialist. The CT scan was rejected by insurance. The problem in my mouth wasn't healing. There was still a small, abnormal growth in that area, and also my left, neck lymph node was still inflamed. He still suspected malignancy. Dr. ordered a CT scan at the Imaging Center. 9/21/21: Received a CT scan at the Imaging Center. There is a problem in my left tonsillar region, the back, left base of my tongue, and an enlarged left neck lymph node. After the image procedure, Dr. there, told me that it may reflect an indolent atypical infection, or squamous cell carcinoma. 9/22/21: Examination with E.N.T. specialist. Results from the CT scan with contrast, gave Dr. more concern of squamous cell carcinoma, and he ordered a US core needle biopsy of the left, inflamed, neck lymph node. 10/13/21: Received a US core needle biopsy of the left neck lymph node. The results were metastatic squamous cell carcinoma. There was minor pain there since the biopsy. 10/19/21: An examination with E.N.T. specialist. Discussed the results from the US core needle biopsy of the left neck lymph node. Dr. concerns of the head and neck metastatic squamous cell carcinoma were confirmed, and he ordered a PET Tumor Scan. 10/28/21: Dental examination with my Dentist. They took full mouth images for Pre-cancer treatment. Other than still having two lower wisdom teeth, he said the X-rays looked ok. 11/19/21: I received a PET/CT scan with contrast. The results were glowing, (cancer presence), in the left tonsillar region, and in the left neck lymph node region. Also, there is a cyst on my right kidney, and BPH located in my pelvis region. No signs of cancer spreading to other parts of the body. The image showed a glow mark in my kidney, Dr. had no concern, he said the contrast had processed there. 11/23/21: Examination with E.N.T. specialist. Discussed the results from the PET/CT scan. Dr. referred me to an Oncologist. She will oversee the treatment of the metastatic squamous cell carcinoma in the left tonsil area of my mouth, and my left neck lymph node. 12/03/21: Annual Medical Examination with N.P. at the Outpatient Clinic. She discussed the results from the blood panel from 11/30/21, and she aid at this time it was normal. I received a quad flu vaccine, and a pneumonia vaccine, and my vitals were good. Also, we discussed the Throat Cancer diagnosis, and she submitted information requesting the authorization from the agency, for Oncology treatment with Dr. 12/10/21: Consultation with the Radiation Oncologist, Dr. She reviewed all of the tests, and scans with me. She discussed Cancer Treatment Plan of more preparation for radiation of the throat and neck area. She also discussed the type of Throat Cancer diagnosis, and a seven week, five treatments a week, (33-35), is the Radiation Plan. The possible short, and long-term side effects were discussed. She highly recommended a gastrointestinal feeding tube to be installed for nutrition, because I wouldn't be able to swallow without throat pain. 12/15/21: Consultation with the Chemotherapy Oncologist Dr. He recommended the Cancer Chemotherapy Cisplatin Treatment Plan of once a week, for seven weeks. He also talked about all the side effects. 12/17/21,12/20/21,12/22/21: Dental examination with my Dentist. He took impressions for Dental guards for radiation treatment. He had difficulty fitting for the bottom tray. Three trips were needed to complete the upper, and lower dental guard trays. 12/27/21: G-Tube installation in my abdomen, out-patient surgery with Medical Center. Changed sponge bandage daily for four months. 12/27/21: Picc-Tube installation in my left, upper arm, out-patient surgery with Medical Center. Changed the bandages once a week for four months. 1/03/22: Appointment to get face and neck impressions for a radiation mask. 1/13/22: Started the neck and mouth radiation treatment. (Five days a week for seven weeks). 1/14/22: Started the Cisplatin chemotherapy treatment. (One day a week for five weeks). 2/10/22: Finished five Cisplatin chemotherapy treatments. I was very nauseous through the treatment. 2/25/22: Finished thirty-two neck and mouth radiation treatments. It created pain in my throat and excessive mucus. 4/15/22: Post treatment examination to discuss the completed treatment throat cancer existing terrible side effects, and recovery with my Oncologist. No cancer symptoms. 4/20/22: Post treatment examination with E.N.T. specialist. He found that there is scarring in the left tonsil region, and the left neck lymph node is normal in size. Discussed the dry mouth, no taste, excessive mucus in my throat, and some difficulty swallowing food and water. No cancer symptoms. 4/25/22: G-Tube, and Picc-line removed, an out-patient procedure. 5/31/22: Post treatment Examination with E.N.T. specialist. He found that there is scarring in the left tonsil region, and the left neck lymph node is normal in size. Discussed the dry mouth, no taste, and some difficulty swallowing food and water. No cancer symptoms. 6/28/22: Post Cancer Treatment PET/CT scan test with contrast. The results were that the squamous cell carcinoma in the left tonsillar region, and in the left neck lymph node region was resolved at this time. No cancer symptoms. 6/29/22: Post treatment examination to discuss the cancer resolution test results with my Oncologist. There are some side effects from the treatment. No cancer symptoms. 8/25/22: Post treatment examination with E.N.T. specialist. The scarring in the left tonsil region has improved, and the left neck lymph node is still a normal size. Discussed my dry mouth, approx. 70% of taste returned, and need to clear my throat after meals. No cancer symptoms. He said there is a possibility that the cancer can return. 11/18/22: Annual Physical examination with N.P. at Outpatient Clinic. She discussed the results from the blood panel from 11/14/22, and she said at this time it was normal. My vitals were good. Also, we discussed the existing throat cancer recovery side effects. The thyroid, white blood count, and red blood count results were normal. 12/02/22: Post treatment examination to discuss the throat cancer recovery progress, and the existing side effects with my Oncologist. No cancer symptoms. She said there is a possibility that the cancer can return.