Date:

Head & Neck MDT Clinic

Case:
Biopsy Date:
CWT:

General Hospital Polonnaruwa

History
1. Demographic data:
a. Name

b. Age

d. Address

e. Occupation:

f. Referral from

g. Referral Rcvd:

h. Consultant

: Dr.Y.S.Mohamed (Consultant Oral & maxillofacial Surgeon)

Yr

c. sex:

2. Complaint:
a. Associated with

b. Difficulty in

c. Tongue movements

d. Parasthesia

e. Tooth mobility

f. Bleeding

3. H/O/C

4. PMH

5. Allergy

6. PDH

7. Family History :
8. Social History

a. Family details :
b. Job

c. Family support:
9. Diet

10. Habits

a. Alcohol

: (Regular/Occasional, How much, frequency, how long, year stopped)

b. Smoking

: (cigarette/Beedi, how much, how long, year stopped)

c. Betel chewing : (How much/ frequency, how long, ingredients, year stopped)
11. Psychological Hx :
a. Understood the condition?

b. Habit intervention

c. Addiction

d. willing to undergo treatment?

e. Family concern
12. Examination
a. General

( a. comfortable

b. depressed

b. Extra orally :
a. Neck

b. Facial asymmetry:

c. dyspnea

d. confused )

c. TMJ

d. SG

e. MO

f. Tethering

c. Intra Orally

Hygiene

Teeth

Mucosa

Ulcers / Growth

a. size:..Xcm
b. where to where

c. shape: margins

d. base

e. discharges

f. induration

Salivary duct openings

Throat

Nose

2. TNM classification

3. Investigations

a.Tumor / Primary site

a. Incisional Bx

b. FNAC

c. X-rays, CT

d.

Endoscopy / FOL

b. Regional spread - neck

e. USS

f. CT

g. FNAC / Sentinel node bx:

c.Distant metastasis
a. CXR

b. USS abdomen

c. CT brain

d. PET

MDT Team:

Head & Neck MDT Summery:

MDT Consultant
Dr.

Consultant Oncologist
Dr.

Consultant OMF Surgeon

1. Primary site

2. Histological Diagnosis

3. Clinical Staging

4. Treatment Intent

Dr.Y.S.Mohamed

5. Planned treatment Modality:

Consultant ENT Surgeon

6. Treatments Received
Consultant Surgeon

Consultant Radiologist

Consultant Pathologist

Consultant Prosthodontist

Nutritionist

Speech Therapist

Head & Neck Nurse