Event 1: Emergency Department Visit

A middle-aged man with a goatee, wearing glasses.
Mr. Gateway

The Emergency Department (ED) calls you and says, “We have a 52-year-old male smoker with a history of substance abuse with recurrent laryngeal cancer who presents with increased throat and neck pain, dysphagia (pain with swallowing), and dehydration.”

You are part of the inter-professional team that will manage Mr. Gateway during his hospitalization. You are asked to come evaluate the patient who will be admitted to the surgical service and help advise on how to manage his pain.

Watch the video to review Mr. Gateway's history and presentation. You'll want to take notes on his history for reference during the case.

Mr. Gateway's History and Presentation

Dr. Barreveld wants to know what brings Mr. Gateway to the emergency department. She then asks him some questions about his medical history. Mr. Gateway explains his troubles with his mouth and throat.

Physical Exam

Vital Signs:

Temperature 97.2, Blood Pressure 152/88, Heart Rate 96, oxygen saturation 96% on room air

General appearance:

Thin man, mild distress

Head, ears, eyes, nose, throat and mouth exam:

Normocephalic, sclera anicteric, conjunctivae pale, oral mucosa dry, oropharynx clear, tongue midline and mobile. Missing molars in the left lower quadrant, mandibular incisor mobility. Decreased mouth opening and jaw range of motion. Numerous broken and unrepaired teeth and some gingival bleeding. There is a 6mm reddish white plaque on the left posterior lateral surface of his tongue


Normal range of motion but neck pain radiating to right shoulder with neck extension, post-radiation skin changes, palpable thyroid with irregularly shaped anterior mass, bilateral submandibular lymphadenopathy


Soft expiratory wheezes otherwise clear


Tachycardic, regular rhythm, no murmurs


Soft, palpable liver tip, no masses, no tenderness to palpation


No cyanosis, clubbing or edema


No rashes


Strength 5/5 upper and lower extremities


Alert and oriented, normal gait, cranial nerves intact

Lab Results

Lab Value Result
White blood cell 6.2
Hematocrit 31.4
Platelets 172
Lab Value Result
Sodium 145
Potassium 3.2
Chloride 109
Bicarbonate 29
Blood Urea Nitrogen (BUN) 33 (elevated level: patient may be dehydrated)
Creatinine 1.5
Liver enzymes
Lab Value Result
Total bilirubin 0.8
aspartate aminotransferase (AST) 82 (AST:ALT ratio of 2:1 may be a sign of chronic alcohol abuse, but other lab values examining liver synthesis are within normal limits: e.g. INR - not shown - and platelet count)
Alanine aminotransferase 39
Alkaline Phosphatase 135
Urine Toxicology
Lab Value Result
oxycodone negative (patient has not taken oxycodone in likely over a week as the oxycodone is not detected by a urine screen 3-4 days after the last dose)
Tetrahydrocannabinol (THC) positive (patient has used marijuana in the recent past)
All other substances negative
CT scan of thyroid cancer
CT scan of thyroid cancer

Imaging Studies

The arrow on this axial image from a computered tomography (CT) scan of the neck shows cancer invading the thyroid.

The CT scan overall demonstrates post-surgical/radiation changes and recurrence of laryngeal mass with thyroid cartilate invasion. Imaging also notable for mass at the base of the tongue and lymphadenopathy (image not shown).

Next Steps

In addition to radiation oncology and oncology input to guide with staging and treatment, a dental consult is initiated to evaluate Mr. Gateway's limited mouth range of motion and mouth pain.

The National Cancer Institute offers excellent guidelines on oral and dental management prior to cancer therapy.

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