食管肿瘤 简易登记表 2页

'河南省肿瘤医院食管癌患者简易登记表ID______一般情况:姓名:__________性别:______年龄:____住院号:_______出生日期:_________________民族:_________职业:_________详细通迅地址:________________________________________________邮编：_____________电话：______________联系人：_______________备用联系电话：_______________入院情况第一次入院时间:__________________入住科室:内科[]外科[]主治医师:身高：____cm体重：______kg近3月来是否体重明显下降？是[](kg)否[]患有其它疾病:糖尿病[]高血压[]其它恶性肿瘤().危险因素：[]不良饮食习惯[]饮酒_____两/天共___年已戒酒是[]____年否[][]吸烟_____支/天共___年,已戒烟是[]____年否[][]返流性食管炎伴随症状出现时间:_________________________________进行性咽下困难[]咽下疼痛[]食管返流[]声音嘶哑[]其它症状:______________________________________________________________________一般检查:全身浅表淋巴结:锁骨上淋巴结,左[],大小____cm____个或融合;右[],大小____cm____个或融合___________淋巴结,左[],大小____cm____个或融合;右[],大小____cm____个或融合___________淋巴结,左[],大小____cm____个或融合;右[],大小____cm____个或融合实验室及辅助检查:CEA______μg/LCA199_______U/mlCA724________U/ml其它_________________上消化道造影:食管癌位于上段[]中段[]下段[]胃镜检查结果:糜烂型[]斑块型[]乳头型[]髓质型[]蕈伞型[]溃疡型[]缩窄型[]其它型______________________________________________________病理报告(术后为准):鳞癌[]腺癌[]小细胞癌[]癌肉瘤[]检查提示其它部位转移:腹水胸水肺肝脑肾骨___________________________________临床分期:有[]否[]T(1)(2)(3)(4)(X)(O)(S)N(1)(2)(3)(X)(O) M(1)(X)(O)(M1aM1b)临床分期:(I)(IIa)(IIb)(III)(IVa)(IVb)0治疗过程:术前化疗:是[]否[]化疗药物:mg/dayday15-fumg/dayday2L-OHPmg/dayday3TAXmg/dayday4BLMmg/dayday5VP-16mg/dayday6ADMmg/dayday7MMCmg/dayday8GEMmg/dayday9NVBmg/dayday10顺铂mg/daydaymg/dayday化疗周期_____化疗最后一次时间:_____________________病情评价:_________________________备注:___________________________________________________________________手术方式:根治性[]姑息性[]放疗治疗:术前术后放疗部位剂量:术后辅助化疗:是[]否[]化疗药物:mg/dayday15-fumg/dayday2L-OHPmg/dayday3TAXmg/dayday4BLMmg/dayday5VP-16mg/dayday6ADMmg/dayday7MMCmg/dayday8GEMmg/dayday9NVBmg/dayday顺铂mg/daydaymg/dayday化疗周期_____化疗最后一次时间:__________________________病情评价:______________________备注:_____________________________________________________________________'