Healthligence

Space Name

Password

Prachi Das

Age/Gender

: 25 years / Male

Address

: Mumbai

Mobile No.

: 9987890987

: IP-091899808

Ward/Bed No.

: --/--

Patient Category

: Planned

Department

: --

Admission Date

: 13 October 2025, 07:08

Discharge Date

: N/A

Consultant Doctor

: --

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FINAL DIAGNOSIS

DIAGNOSIS

ICD CODE

DISEASE ONE

C12.9

PRESENTING COMPLAINTS

Admitted for chemotherapy

EXAMINATION ON ARRIVAL

ECOG 1 Conscious, Oriented, Afebrile BP - 120/80 mmHg, RR - 20/min, SpO2 100% on room air, RBS 113mg/dIN No Mucositis, No Skin Reaction Chest - B/L clear, CVS - S1,S2 (N), CNS - NAD, P/A - Soft, BS (+), Height- 170 cms, Weight- 70 Kg, BSA - 1.71

HISTORY OF PRESENT ILLNESS

Patient presented with dysphagia in Dec 22. He was evaluated with following investigations: CECT neck : soft tissue density mass lesion~ 26x 19x 17mm involving the left AE fold and left glottis with obliteration of the left PFS, extension renal caudally to involve both the true and the false vocal cords on the left side along with thickening of the anterior commissure and increased density of the left arytenoid cartilage along with few sub-centimetric level II and level III lymph nodes on the left side (largest approx. 8x 7 mm). He underwent Direct Laryngoscopy + Biopsy done on 18/12/2022 which showed: superficial ulcerative lesion over left false cords near posterior commissure. 1st Biopsy: superficial epithelium seen Repeat Biopsy was done on 31/12/2022: S/O Focus of squamous cell carcinoma (Superficially invasive).

COURSE DURING HOSPITAL STAY

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DISCHARGE MEDICATION

SR.No

MEDICINE

DOSAGE INSTRUCTION

DURATION

FOLLOW UP

Review on 01/02/2023 with Dr. Amarjeet Chaterjee/ Dr. Tushar Deshpande in OPD for cycle 2 chemotherapy. Triple gargles q4h (Sodabicarb 2 tbsf + Benadryl 2tbsf + glycerine 2tbsf to be mixed with 1 glass water) TREATMENT PLAN : CTRT with concurrent Cisplatin Any Other Instruction: Do not stop any medication without doctor advice STEAM INHALATION TDS x 1 WEEK Diet: Neutropenic high protein diet Consult Doctor/Hospital In Case of: Pain, Fever, Vomiting

TREATMENT PLAN :

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Activity :

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Diet:

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Physiotherapy:

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Patient Education:

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Wound Care Instruction:

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Counselling Instruction:

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Rehabilitation:

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Red Flag Symptoms:

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