Head & Neck MDT:
Patient Details:
- John Doe
- 01/15/1970
- MRN: 123456
Clinical History:
- Presenting Complaints: Persistent sore throat and difficulty swallowing
- Past Medical History: Hypertension, Type 2 Diabetes
- Previous Surgeries: Appendectomy in 2005
- Medications and Herbal Supplements: Metformin, Lisinopril
- Allergies: Penicillin
- Social History: Non-smoker, occasional alcohol use
Examination Findings:
- General Examination Findings: Alert and oriented, no acute distress
- Head and Neck Examination Findings: Enlarged cervical lymph nodes, erythematous oropharynx
Investigations:
- Imaging Results: CT scan shows a mass in the oropharynx
- Biopsy Results: Squamous cell carcinoma
- Blood Test Results: Elevated white blood cell count
Diagnosis:
- Primary Diagnosis: Oropharyngeal squamous cell carcinoma
- Secondary Diagnoses: None
Management Plan:
- Surgical Plan: Scheduled for partial pharyngectomy
- Medical Treatment Plan: Start on high-dose antibiotics
- Radiotherapy Plan: To be considered post-surgery
- Follow-up Plan: Weekly follow-up with oncology
Discussion Points:
- Discussion Points from MDT Meeting: Need for nutritional support, potential complications of surgery
Recommendations:
- Recommendations from MDT: Pre-operative nutritional assessment, post-operative radiotherapy
Next Steps:
- Next Steps for Patient Management: Schedule surgery, arrange pre-operative assessments, plan for post-operative care
Head & Neck MDT:
Patient Details:
- [Patient Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Patient Date of Birth] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Patient Medical Record Number] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Clinical History:
- [Presenting Complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Past Medical History] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Previous Surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Medications and Herbal Supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Social History] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Examination Findings:
- [General Examination Findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Head and Neck Examination Findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Investigations:
- [Imaging Results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Biopsy Results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Blood Test Results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Diagnosis:
- [Primary Diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Secondary Diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Management Plan:
- [Surgical Plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Medical Treatment Plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Radiotherapy Plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Follow-up Plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Discussion Points:
- [Discussion Points from MDT Meeting] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Recommendations:
- [Recommendations from MDT] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Next Steps:
- [Next Steps for Patient Management] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)