DEPARTMENT of RESPIRATORY MEDICINE CHEST CONFERENCE Please Email the Completed Form To

FORMTEXT - FORMTEXT

Page 1 of 2

Fax: 07 839 8770Ph: 07839 8899 Ext.96447

DEPARTMENT OF RESPIRATORY MEDICINE CHEST CONFERENCE Please Email the completed form to:

Referral/s from MDM to: MedOncRadOncMedOnc and RadOncCardiothoracic
DDemographics & Referral MDM Date
First name: / Surname:
Referral date: / Domicile DHB: / BOPLakesWaikatoTairawhitiTaranaki
NHI: / DOB:
Ethnicity: / European=10NZ European / Pakeha=11NZ Maori=21Pacific Island=30Samoan=31Cook Island Maori=32Tongan=33Tokelauan=35Fijian=36Other Pacific=37Asian=40South East Asian=41Chinese=42Indian=43Other Asian=44Middle Eastern=51Latin American / Hispanic=52African=53Others=54Unknown/unstated=98Not Stated=99 (Enter no of Ethnicity) / Age:
Previous conference: / Sex: / F M
Referring consultant:
CC (GP):
CC (Others):
Triaged HSCAN: YESNO FSA within 2 weeks : YESNO HSCANbreach date 62 day FCT :
If referred in from another DHB (mandatory):
Address:
Phone no:
Diagnosis
Diagnosis:
Other :
Pathology: / Carcinoid neoplasiaMesotheliomaSmall cell carcinomaThymic neoplasiaNSCLC: AdenocarcinomaNSCLC: Squamous cell carcinomaNSCLC: OtherNSCLC: Large cell carcinomaNSCLC:Adenocarcinoma (lepidic predominant pattern)NSCLC: NOS
Laterality: / LeftRightNot applicable
Staging
Clinical: / T / X011a1b22a2b341a(mi)1c / N / X0123 / M / X01a1b11c / Stage grouping: / IAIBIIAIIBIIIAIIIBIVUOIA1IA2IA3IIIIIIIIICIVAIVBRecurrence
Pathological: / T / X011a1b22a2b341a(mi)1c / N / X0123 / M / X01a1b1c
Co-morbidities
COPDCardiovascularDiabetesRenal FailureOther MalignancyAnticoagulant TherapyCerebrovascularDementia / COPDCardiovascularDiabetesRenal FailureOther MalignancyAnticoagulant TherapyCerebrovascularDementia / COPDCardiovascularDiabetesRenal FailureOther MalignancyAnticoagulant TherapyCerebrovascularDementia
COPDCardiovascularDiabetesRenal FailureOther MalignancyAnticoagulant TherapyCerebrovascularDementia / COPDCardiovascularDiabetesRenal FailureOther MalignancyAnticoagulant TherapyCerebrovascularDementia / COPDCardiovascularDiabetesRenal FailureOther MalignancyAnticoagulant TherapyCerebrovascularDementia
Additional details:
Clinical details / (Please include presenting symptoms and length of symptoms e.g. cough, dyspnoea, haemoptysis, lymphadenopathy, chest/shoulder pain, hoarseness, fatigue, weight loss, finger clubbing).
History:
ECOG Status(Mandatory)

Select: 0 1 2 3 4 Unrecorded
Additional details:
Weight Loss > 10% in last 6 months? / YNU / Asbestos Exposure? / UNY
Question for conference
Smoking history
Status / NeverEx SmokerCurrent / Number of Cigarettes a Day / Number of years smoked
If ex smoker, for how long? / Pack Year
Bloods
Date: / CBC / Hb / Platelets / WBC
Date: / Renal / Na / K / Cr
Date: / Liver / Alb / Alk Phos / ALT / Ca / cCa
Date: / CEA / INR / APTT
Molecular markers
Date:
EGFR: / PositiveNegativeIndeterminateNot donePending / ALK: / PositiveNegativeIndeterminateNot done
Lung function Test
Date:
FEV₁: / ( % Pred.)
FVC: / ( % Pred.)
DLCO: / ( % Pred.)
KCO: / ( % Pred.)
Key Investigations
Mode of diagnosis? (tick one)
Date / Chest X-RayStaging CT scanCT- PETCT/ MRI HeadCT BiopsyBronchoscopyEBUSMediastinoscopyMediastinotomyThoracoscopyThoracotomyPleural fluid cytology CTPAHRCTU/S BiopsyPleural Biopsy
Date / Chest X-RayStaging CT scanCT- PETCT/ MRI HeadCT BiopsyBronchoscopyEBUSMediastinoscopyMediastinotomyThoracoscopyThoracotomyPleural fluid cytology CTPAHRCTU/S BiopsyPleural Biopsy
Date / Chest X-RayStaging CT scanCT- PETCT/ MRI HeadCT BiopsyBronchoscopyEBUSMediastinoscopyMediastinotomyThoracoscopyThoracotomyPleural fluid cytology CTPAHRCTU/S BiopsyPleural Biopsy
Date / Chest X-RayStaging CT scanCT- PETCT/ MRI HeadCT BiopsyBronchoscopyEBUSMediastinoscopyMediastinotomyThoracoscopyThoracotomyPleural fluid cytology CTPAHRCTPleural Biopsy
Date / Chest X-RayStaging CT scanCT- PETCT/ MRI HeadCT BiopsyBronchoscopyEBUSMediastinoscopyMediastinotomyThoracoscopyThoracotomyPleural fluid cytology CTPAHRCTU/S BiopsyPleural Biopsy
Date / Chest X-RayStaging CT scanCT- PETCT/ MRI HeadCT BiopsyBronchoscopyEBUSMediastinoscopyMediastinotomyThoracoscopyThoracotomyPleural fluid cytology CTPAHRCTU/S BiopsyPleural Biopsy
Pathology
Bronchoscopy / (Please state date, who it was performed by and a brief report).
Radiology (e.g. CXR,CT,PET.Please state date, location and a brief report).
Other Investigations
Discussion
Plan
Treatment intent:CurativeNon-curativeNot Defined at Meeting
Reason for Non curative Management If Applicable: / Advanced stageCo morbiditiesPatient wishes
Primary management: SurgeryChemotherapyRadiation therapyTargeted therapyActive MonitoringSequential chemotherapy and radiotherapyConcurrent chemotherapy and radiotherapyPalliative careNon-intervention management (expectant treatment)Adjuvent chemo/radiation therapy following surgeryFurther investigationOther, please specify
Action:
Form completed by:
Person responsible for action:
MDM attendees: