Case Reporting Form (CRF)

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Demography

Trial ID: T-001
Initials: JD
Gender: Female
Age: 45
Date of Entry: 07/12/2025

Habit Details

Habit Name Status From Age To Age Frequency/Day
Smoking Stopped a year ago 25 29 4
Alcohol Current regular User 25 29 1

Clinical Course Details

Diagnosis & Staging

Site: Oral Cavity

Subsite: Tongue

TNM: T:T2 N:N0 M:M0

Dimensions: Max: 3 cm, Min: 2 cm

Biopsy Report: SCC

Treatment History

Prior Radiotherapy: Yes (60G in 30#)

Prior Chemotherapy: Yes (Cisplatin)

Treatment Plan: Surgery


Surgery & Hospital Course

Admission Date: 01/12/2025

Surgery Date: 02/12/2025

Primary Surgery: WLE

Neck Dissection: Level I, Level II, Level III, Level IV

Reconstruction: Local flap

Post-Op & Discharge

Course in Hospital: Uneventful

Tracheostomy: Yes

NG Tube: Yes

NG Tube Removal Date: 07/12/2025

Discharge Date: 08/12/2025