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10/17/2017 Tata Memorial Hospital-Electronic Medical Record

EMR Patient Clinical Evaluation Investigations Treatment Post Treatment Evaluation Followup

Name: Mr. KAILASH NATH Sex/Age/Catg: Male /53 yrs/ Pvt-B


Case No. CP/34174
... DMG : DMG - HEAD & NECK(B) Regn. Date: 9/10/2017

Smart Card Balance (Rs.) : 40

Contact No(s) : 8090613970 ;8090613970 ;08090352708

Hist. & Exam. No. ALL

REMARKS & ADDENDUM DETAILS

Hist.& Exam.No : 2 Assessment Type : INTERMEDIATE Service/Unit : DMG - HEAD & NECK
Date & Time : 16/10/2017 & 16:21 Seen by : DR.S. S. KUNDER
Transcribed By : S. S. KUNDER Transcription Date : 16/10/2017

Remarks : Med Onc OPD

53yr/M, R/o UP, No Comorbidities, chronic tobacco chewer 15-20 yrs reformed since 2 yrs,
P/W ulcer over Rt cheek mucosal side.

Evaluated outside:
Bx- MDSCC
CECT(9/9/17)- Irregular thickening in the Rt BM about 5.4 x 1.2 x 3.8 cm from Lat incisor to 2nd Molar posteriorly. Fat
planes with Massetter maintained. Skin free.
Rt Level II node 1.2 x 1.1 cm

OnExam- GC- Good KPS -80


Oral cavity- MO- Adequate- 6 cm
Oral hygiene- Stained teeth
Ulcer seen on Rt BM from Lat incisor on the lip mucosal surface to 2nd Molar indurated ulcerated growth.
Neck- No palpable nodes

Imp- Ca Rt BM T3N2bM0 MDSCC


Planned for Sx

Labs- Increased ALT


Increased FBS

s/b Dr Vijay patil sir


Increased ALT is within 1.5 ULN
can be randomised for trial
Addendum : ADDENDUM NOT ENTERED/FOUND ON THE SYSTEM

Hist.& Exam.No : 1 Assessment Type : PRELIMINARY Service/Unit : DMG - HEAD & NECK
Date & Time : 09/10/2017 & 15:06 Seen by : DR.PRIYANKA J HARDIKAR
Transcribed By : PRIYANKA J HARDIKAR Transcription Date : 09/10/2017

Remarks : REMARKS NOT ENTERED/FOUND ON THE SYSTEM


Addendum : ADDENDUM NOT ENTERED/FOUND ON THE SYSTEM

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10/17/2017 Tata Memorial Hospital-Electronic Medical Record

Tata Memorial Hospital, Dr. E. Borges Road, Parel, Mumbai - 400 012 India. Tel. +91-22-24177000, 24146750 - 55
Fax: +91-22-24146937 E-mail: ms@tmc.gov.in

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