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Case #1

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Expand Physical Exam

02/14/XX

Right vocal cord covered with a fungating lesion. Lesion does not extend beyond true vocal cord. Neck: supple. No nodes palpable.

Expand X-Rays & Scans

02/15/XX

CXR: Lungs are clear. No acute disease.

Expand Laboratory

None.

Expand Scopes

See operative findings.

Expand Operative Findings

02/26/XX

Direct laryngoscopy and biopsy. Findings: Entire surface of right vocal cord covered with a fungating mass. Mass extended partially into ventricle and approximately 2 mm over the free margin onto inferior border of the vocal cord.

Expand Pathological Reports

02/26/XX

Biopsy of larynx: Invasive moderately differentiated keratinizing squamous cell carcinoma.

Expand Treatment

03/05/XX

Radiation: 6480 rads to glottis (6 MV) at staff physician's office.