Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Initial evaluation for suspected oropharyngeal cancer
Follow-up for diagnosed oropharyngeal cancer (treatment, surveillance)
Evaluation of treatment side effects or complications
Chief Complaint:
(May vary depending on stage)
Sore throat that won’t go away
Difficulty swallowing (dysphagia)
Earache (otalgia) on one side
Lump in the neck (cervical lymphadenopathy)
Hoarseness or changes in voice
Weight loss
History of Present Illness:
Onset, duration, and severity of symptoms.
Progression of symptoms over time.
Presence of any risk factors (HPV infection, tobacco use, excessive
alcohol consumption).
Previous history of head and neck cancers.
Past Medical History:
Underlying medical conditions (e.g., weakened immune system).
Previous surgeries or radiation therapy to the head and neck.
Social History:
Tobacco use history (cigarettes, smokeless tobacco).
Alcohol consumption habits.
Sexual history (risk factors for HPV infection).
Family History:
Family history of head and neck cancers.
Physical Examination:
Head and neck examination: Palpate for masses or enlarged lymph nodes
in the neck. Evaluate the oral cavity, pharynx, and larynx for
suspicious lesions or abnormalities.
Ear, nose, and throat (ENT) examination: Assess for otorhinolaryngologic
findings consistent with oropharyngeal cancer (e.g., unilateral tonsillar
enlargement, vocal cord paralysis).
Diagnostic Tests:
Imaging studies: May include:
CT scan or MRI scan of the head and neck: To visualize the extent of
the tumor and assess for lymph node involvement.
PET scan: May be used to assess for distant metastases.
Biopsy:** Tissue sample from the suspicious lesion is essential for
definitive diagnosis. Biopsy can be obtained through various techniques
depending on the location (e.g., fine-needle aspiration, tonsillectomy).
HPV testing:** To determine if the oropharyngeal cancer is HPV-positive.
HPV-positive oropharyngeal cancers tend to have a better prognosis.
Assessment:
Suspected oropharyngeal cancer: Based on clinical presentation
(symptoms and physical examination findings) and supported by imaging studies.
Diagnosed oropharyngeal cancer: Confirmed by biopsy and pathological
examination. Stage of the cancer (extent of local and distant spread)
should be determined using the TNM staging system.
HPV status: HPV-positive or HPV-negative oropharyngeal cancer.
Differential Diagnoses:
Consider other conditions that may mimic oropharyngeal cancer:
Tonsillitis
Pharyngitis (inflammation of the pharynx)
Abscess (collection of pus) in the neck
Benign tumors of the head and neck
Plan:
Treatment plan: Depends on the stage and HPV status of the cancer.
Treatment options may include:
Surgery: To remove the tumor and potentially surrounding lymph nodes.
Radiation therapy: Delivered externally or internally (brachytherapy).
Chemotherapy: May be used alone or in combination with radiation
therapy.
Targeted therapy: Newer medications may be used for specific
mutations found in some oropharyngeal cancers.
Multidisciplinary approach: Treatment typically involves collaboration
between oncologists, surgeons, radiation oncologists, and other specialists
depending on the specific needs of the patient.
Supportive care: Manage side effects of treatment and improve
quality of life. May include pain management, nutritional counseling, and
speech therapy.
Surveillance: Regular follow-up appointments with monitoring for
recurrence after treatment completion.
Prognosis:
Prognosis depends on the stage and HPV status of the cancer.