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  • Tata Memorial Hospital-Electronic Medical Record REMARKS

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    SATISH KUMAR
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    This document contains an electronic medical record from Tata Memorial Hospital for a 53-year-old male patient named Mr. Kailash Nath who presented with an ulcer on his right cheek. The record notes his medical history including a 15-20 year history of tobacco chewing and a prior biopsy showing moderately differentiated squamous cell carcinoma. A CT scan showed a tumor in the right buccal mucosa and an enlarged right lymph node. On examination, an indurated ulcerated growth was seen in the right buccal mucosa. Laboratory tests showed increased ALT and fasting blood sugar. The patient is planned for surgery and may be randomized for a clinical trial due to his increased ALT being within normal limits.

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    FINAL TREATMENT REPORT

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    This document contains an electronic medical record from Tata Memorial Hospital for a 53-year-old male patient named Mr. Kailash Nath who presented with an ulcer on his right cheek. The record notes his medical history including a 15-20 year history of tobacco chewing and a prior biopsy showing moderately differentiated squamous cell carcinoma. A CT scan showed a tumor in the right buccal mucosa and an enlarged right lymph node. On examination, an indurated ulcerated growth was seen in the right buccal mucosa. Laboratory tests showed increased ALT and fasting blood sugar. The patient is planned for surgery and may be randomized for a clinical trial due to his increased ALT being within normal limits.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    2K views2 pages

    Tata Memorial Hospital-Electronic Medical Record REMARKS

    Uploaded by

    SATISH KUMAR
    This document contains an electronic medical record from Tata Memorial Hospital for a 53-year-old male patient named Mr. Kailash Nath who presented with an ulcer on his right cheek. The record notes his medical history including a 15-20 year history of tobacco chewing and a prior biopsy showing moderately differentiated squamous cell carcinoma. A CT scan showed a tumor in the right buccal mucosa and an enlarged right lymph node. On examination, an indurated ulcerated growth was seen in the right buccal mucosa. Laboratory tests showed increased ALT and fasting blood sugar. The patient is planned for surgery and may be randomized for a clinical trial due to his increased ALT being within normal limits.

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    © All Rights Reserved
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    of 2

    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

    https://tmc.gov.in/webemr/RemarksAdd.asp 1/2
    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

    https://tmc.gov.in/webemr/RemarksAdd.asp 2/2

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