右半结肠癌病历模板

右半结肠癌病历模板
英文回答：
Patient Information.
Name: [Patient Name]
Age: [Patient Age]
Sex: [Patient Sex]
Date of Birth: [Patient Date of Birth]
Medical History.
Past medical history:
Any previous cancer diagnoses or treatments: [Previous Cancer History]
Other significant medical conditions: [Other Medical Conditions]
Current medications: [Current Medications]
Presenting Symptoms.
Onset and duration of symptoms: [Symptom Onset and Duration]
Nature of symptoms: [Symptom Description]
Any associated constitutional symptoms (e.g., fever, fatigue, weight loss): [Constitutional Symptoms]
Physical Examination.
General appearance: [General Appearance]
Abdominal examination:
Masses or tenderness: [Abdominal Masses or
Tenderness]
Enlarged lymph nodes: [Enlarged Lymph Nodes]
Ascites or hepatomegaly: [Ascites or Hepatomegaly]
Rectal examination: [Rectal Examination Findings]
Diagnostic Studies.
Imaging studies:
Computed tomography (CT) scan of abdomen and pelvis: [CT Scan Findings]
Colonoscopy with biopsy: [Colonoscopy Findings and Biopsy Results]
Laboratory tests:
Complete blood count (CBC): [CBC Results]
Liver function tests (LFTs): [LFT Results]
CEA level: [CEA Level]
Pathology Report.
Histological diagnosis: Right-sided colon adenocarcinoma.
Tumor grade: [Tumor Grade]
Stage: [Tumor Stage]
Immunohistochemistry results: [Immunohistochemistry Results]
Treatment Plan.
Surgery:
Type of surgery: [Surgery Type]
Extent of resection: [Resection Extent]
Adjuvant therapy:
Chemotherapy: [Chemotherapy Regimen]
Radiation therapy: [Radiation Therapy Plan]
Follow-up plan: [Follow-Up Plan]
Prognosis.
Overall prognosis: [Prognosis Statement]
Five-year survival rate: [Five-Year Survival Rate] 中文回答：
患者信息。

姓名， [患者姓名]
年龄， [患者年龄]
性别， [患者性别]
出生日期， [患者出生日期]
病史。

既往病史：
之前曾诊断为癌症或接受过癌症治疗的记录， [癌症史] 其他重要的疾病， [其他疾病]
当前服用的药物， [当前药物]
症状表现。

症状的开始和持续时间， [症状开始时间和持续时间]
症状的类型， [症状描述]
任何相关的全身症状（例如，发烧、疲劳、体重减轻）， [全身症状]
体格检查。

全身状况， [全身状况]
腹部检查：
肿块或压痛， [腹部肿块或压痛]
淋巴结肿大， [淋巴结肿大]
腹水或肝大， [腹水或肝大]
直肠指检， [直肠指检结果]
诊断检查。

影像学检查：
腹部和骨盆计算机断层扫描（CT）扫描， [CT 扫描结果]
结肠镜检查和活检， [结肠镜检查结果和活检结果] 实验室检查：
全血细胞计数（CBC）， [CBC 结果]
肝功能检查（LFT）， [LFT 结果]
CEA 水平， [CEA 水平]
病理报告。

组织学诊断，右侧结肠腺癌。

肿瘤分级， [肿瘤分级]
分期， [肿瘤分期]
免疫组织化学结果， [免疫组织化学结果]
治疗计划。

手术：
手术类型， [手术类型]
切除范围， [切除范围] 辅助治疗：
化疗， [化疗方案]
放疗， [放疗计划]
随访计划， [随访计划]
预后。

预后概况， [预后说明]
五年生存率， [五年生存率]。