Headings
Risk factors · Extraoral exam · Lymph nodes · Intraoral soft tissue exam · Findings · Referral · Follow-up
When to use it
Use this when you do a focused head and neck soft tissue exam, most often for patients with tobacco or alcohol risk or a lesion you want to follow. It records the exact site, size and look of any finding, and whether you referred. That makes it the note to reach for when a lesion needs a biopsy.
Example
Fictional example
Risk factors
Age 58. One pack a day for 30 years. Three beers most nights.
Extraoral exam
Face symmetric. No masses.
Lymph nodes
Submandibular and cervical nodes not palpable.
Intraoral soft tissue exam
1.2 cm white patch, left lateral border of tongue. Does not wipe off. Non-tender.
Findings
Leukoplakia, left lateral tongue. Measured and photographed. No local irritant found.
Referral
Oral surgeon for biopsy. Referral letter sent today.
Follow-up
Call in 2 weeks to confirm biopsy date. Smoking cessation resources given.