308 lines
13 KiB
Plaintext
308 lines
13 KiB
Plaintext
English French Notes Complete/Exclude
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CISPLATIN..........: NA INTERFERON.........: NA
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BCNU...............: NA CYTARABINE (ARA-C).: NA
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BCNU WAFER IMPLANT.: NA OTHER..............: NA
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1383 BCNU WAFER IMPLANT...........
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81. OTHER TYPE OF SUBSEQUENT TX FOR RECURRENCE/PROGRESSION...: None
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1393 81. OTHER TYPE OF SUBSEQUENT TX FOR RECURRENCE/PROGRESSION...
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82. DATE OF LAST CONTACT OR DEATH
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83. VITAL STATUS
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84. CANCER STATUS
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STATUS AT LAST CONTACT
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82. DATE OF LAST CONTACT OR DEATH..:
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15 83. VITAL STATUS...................
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84. CANCER STATUS..................:
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1. FACILITY ID NUMBER (FIN)......:
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2. ACCESSION NUMBER..............:
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3. SEQUENCE NUMBER...............:
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4. POSTAL CODE AT DIAGNOSIS......:
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5. DATE OF BIRTH.................:
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7. SPANISH ORIGIN................:
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10. PRIOR EXPOSURE TO RADIATION...:
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11. PRIMARY PAYER AT DIAGNOSIS....:
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12. PRIOR MEDICAL CONDITIONS:
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MULTIPLE SCLEROSIS (MS)......:
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MYOCARDIAL INFARCTION (MI)...:
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CEREBROVASCULAR DISEASE......:
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MALIGNANT MELANOMA...........:
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OTHER SKIN CANCER............:
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COLON OR OTHER GI CANCERS....:
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14. GENETIC PREDISPOSITION:
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VON HIPPEL-LINDAU DISEASE....:
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TUBEROUS SCLEROSIS...........:
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TURCOT SYNDROME..............:
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LI-FRAUMENI SYNDROME.........:
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KOWDEN DISEASE...............:
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NEVOID BASAL CELL CARCINOMA
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15. USUAL OCCUPATION.............:
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16. USUAL INDUSTRY...............:
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17. CLASS OF CASE.................:
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CHANGE IN SENSE OF SMELL AND/
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OR TASTE....................:
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ALTERED ALERTNESS............:
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SPEECH DISTURBANCE...........:
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PERSONALITY CHANGES..........:
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MEMORY LOSS..................:
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LACK OF CONCENTRATION........:
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DOUBLE VISION................:
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OTHER VISUAL DISTURBANCE.....:
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DECREASED HEARING............:
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WEAKNESS OR PARALYSIS........:
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DIFFICULTY IN COORDINATION/
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GENERALIZED SEIZURE..........:
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FOCAL SEIZURE................:
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BLADDER INCONTINENCE.........:
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BOWEL INCONTINENCE...........:
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PAIN (OTHER THAN HEADACHE)...:
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WEIGHT CHANGE................:
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Print Intracranial & CNS PCE
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19. NEUROLOGICAL FINDINGS:
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MEMORY OR JUDGEMENT..........:
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VISUAL ACUITY................:
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VISUAL FIELDS................:
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EYE MOVEMENTS (EOM)..........:
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FACIAL SENSATION.............:
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FACIAL MOVEMENT..............:
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GAG REFLEX...................:
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SHRUG STRENGTH..............:
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ARTICULATION OR ENUNCIATION..:
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TONGUE FASCICULATIONS OR
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DECREASE IN SENSATION OF ANY
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CORTICAL SENSORY DEFICIT.....:
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WEAKNESS, ATROPHY OR
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FASCICULATION OF ANY SITE...:
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ATAXIA OF GAIT...............:
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TRUNCAL ATAXIA...............:
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RAPID ALTERNATING MOVEMENTS..:
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FINGER TO FINGER NOSE TESTING:
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HEEL TO KNEE TO SHIN TESTING.:
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DEEP TENDON REFLEXES IN UPPER
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DEEP TENDON REFLEXES IN LOWER
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BABINSKI SIGN................:
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HOFFMAN REFLEX...............:
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OTHER ABNORMAL REFLEXES......:
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20. PRE-THERAPY DIAGNOSTIC STUDIES:
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CT SCAN OF BRAIN.............:
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CT SCAN OF SPINE.............:
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ISOTOPE BRAIN SCAN...........:
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SPECT SCAN...................:
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MRI OF BRAIN.................:
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MRI OF SPINE.................:
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FUNCTIONAL MRI...............:
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21. TUMOR LOCATION/INVOLVEMENT:
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FRONTAL LOBE.................:
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TEMPORAL LOBE................:
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PARIETAL LOBE................:
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OCCIPITAL LOBE...............:
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OPTIC NERVES.................:
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PITUITARY GLAND..............:
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PINEAL GLAND.................:
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BRAIN STEM...................:
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SKULL BASE...................:
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OTHER SKULL..................:
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SPINAL CORD..................:
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CEREBRAL SPINAL FLUID........:
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CRANIAL MENINGES.............:
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SPINAL MENINGES..............:
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23. NUMBER OF TUMORS..............:
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24. DATE OF FIRST SYMPTOMS........:
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25. DATE OF INITIAL DIAGNOSIS.....:
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26. DATE OF PATHOLOGIC DIAGNOSIS..:
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27. PRIMARY SITE (ICD-O-2)........:
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28. WHO HISTOLOGICAL CLASSIFI-
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CATION OF TUMOR..............:
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29. BEHAVIOR CODE (ICD-O-2).......:
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31. DIAGNOSTIC CONFIRMATION.......:
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32. MOLECULAR MARKERS.............:
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33. TUMOR SIZE....................:
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34. TUMOR SIZE (SOURCE)...........:
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35. KARNOFSKY'S RATING PRIOR TO TX:
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36. PROTOCOL PARTICIPATION........:
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37. PROTOCOL PHASE................:
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38. DATE OF FIRST COURSE TREATMENT:
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39. DATE OF INPATIENT ADMISSION...:
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40. DATE OF INPATIENT DISCHARGE...:
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41. DATE OF NON CANCER-DIRECTED
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NONE, NO NON CA-DIRECTED
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SURGICAL PROCEDURE..........:
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VENTRICULOSTOMY, OR EXTERNAL
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VENTRICULAR DRAIN...........:
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CSF SHUNT,
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THIRD VENTRICULOSTOMY.......:
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STEREOTACTIC BIOPSY..........:
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OPEN BRAIN BIOPSY............:
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OPEN BIOPSY OF SPINAL CORD
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LAMINECTOMY FOR SPINAL CORD
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TUMOR, W/O TUMOR RESECTION,
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W/O OPENING DURA...........:
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W OPENING DURA.............:
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UNKNOWN IF SURGERY DONE......:
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43. DATE OF CA-DIRECTED SURGERY...:
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44. SURGICAL APPROACH.............:
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45. EXTENT OF SURGICAL RESECTION..:
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46. SIZE OF RESIDUAL PRIMARY TUMOR
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AFTER CA-DIR SURGERY.........:
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47. SIZE OF RESIDUAL PRIMARY TUMOR
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AFTER CA-DIR SURGERY (SOURCE):
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ANESTHETIC PROBLEM...........:
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HEMORRHAGE AT OPERATIVE SITE.:
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DVT (DEEP VENOUS THROMBOSIS).:
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PERSISTENT NEUROLOGICAL
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WORSENING > 4 DAYS POST-OP..:
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49. REASON FOR NO SURGERY.........:
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50. RADIATION THERAPY.............:
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51. DATE RADIATION STARTED........:
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52. DATE RADIATION ENDED..........:
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53. TOTAL RADIATION DOSE (cGy)....:
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54. NUMBER OF TREATMENTS TO THIS
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55. TYPE OF EXT BEAM RADIATION....:
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56. INTERSTITIAL RAD/BRACHYTHERAPY:
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57. STEREOTACTIC RADIOSURGERY.....:
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58. RADIATION/SURGERY SEQUENCE....:
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59. RADIATION COMPLICATIONS:
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SKIN REACTIONS...............:
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NAUSEA OR VOMITING...........:
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NEUROLOGIC WORSENING.........:
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60. REASON FOR NO RADIATION.......:
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61. DATE CHEMOTHERAPY STARTED.....:
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BCNU, WAFER IMPLANT..........:
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64. CHEMOTHERAPEUTIC ROUTE........:
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65. CHEMOTHERAPY COMPLICATIONS:
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HEARING LOSS.................:
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NAUSEA AND VOMITING REQUIRING
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CESSATION OF CHEMOTHERAPY...:
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PERIPHERAL BLOOD COUNT DROP/
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/BLEEDING/CESSATION OF CHEMO
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AND/OR TRANSFUSION..........:
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PERIPHERAL NEUROPATHY........:
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RENAL FAILURE................:
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PULMONARY TOXICITY...........:
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66. REASON FOR NO CHEMOTHERAPY....:
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67. DATE OTHER TREATMENT STARTED..:
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68. OTHER TREATMENT...............:
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69. KARNOFSKY'S RATING AT TIME OF
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RECURRENCE/PROGRESSION
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70. DATE OF FIRST RECURRENCE......:
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71. TYPE OF FIRST RECURRENCE......:
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72. DATE OF PROGRESSION...........:
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73. TYPE OF PROGRESSION...........:
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75. KARNOFSKY'S RATING AT TIME OF
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SUBSEQUENT TREATMENT
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76. DATE OF SUBSEQUENT TREATMENT
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FOR RECURRENCE/PROGRESSION...:
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77. PROTOCOL PARTCIPATION
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(SUBSEQUENT TREATMENT).......:
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78. TYPE OF SUBSEQUENT SURGICAL TX
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79. TYPE OF SUBSEQUENT RADIATION
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TX FOR RECURRENCE/PROGRESSION:
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81. OTHER TYPE OF SUBSEQUENT TX
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STATUS AT LAST CONTACT
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82. DATE OF LAST CONTACT OR DEATH.:
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83. VITAL STATUS..................:
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84. CANCER STATUS.................:
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2001 Patient Care Evaluation Study of Non-Small Cell Lung Carcinoma
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1400 CO-MORBID CONDITION #1.......
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1400.1 CO-MORBID CONDITION #2.......
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1400.2 CO-MORBID CONDITION #3.......
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1400.3 CO-MORBID CONDITION #4.......
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1400.4 CO-MORBID CONDITION #5.......
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1400.5 CO-MORBID CONDITION #6.......
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1401 2. DURATION OF TOBACCO USE.......
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1403 3. PERSONAL HISTORY OF OTHER INVASIVE MALIGNANCIES PRIOR TO THIS CANCER DIAGNOSIS....//^S X=PHDEF
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This item describes the patient's prior history of other invasive
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malignancies. If the patient has a history of other malignancies
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report the ICD-O-3 site code for the most recently diagnosed disease.
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If the patient has no personal history of other cancer, code C88.8. If
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the patient's personal history of other invasive malignancies is not
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Allowable Codes: C00.0 thru C80.9 - valid ICD-0-3 site (topography) codes
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C88.8 - no personal history of other cancer
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C99.9 - personal history of other cancer not documented
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This patient has no other primaries.
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Other primaries for this patient:
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Date DX
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TUMOR IDENTIFICATION AND DIAGNOSIS
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4. SYMPTOMS PRESENT AT INITIAL DIAGNOSIS:
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1404.1 SHORTNESS OF BREATH..........
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1404.2 WEIGHT LOSS..................
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1404.4 PALPABLE LYMPH NODES.........
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5. SCREENING FOR HIGH RISK/ASYMPTOMATIC PRESENTATION:
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1405.1 CT SCAN......................
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6. INITIAL DIAGNOSTIC STUDIES (PRE-THERAPY):
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1406 HISTORY AND PHYSICAL.........
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1406.4 THOROCOTOMY/OPEN BIOPSY......
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TUMOR EVALUATION
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7. PULMONARY FUNCTION TESTS:
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1407 FVC (forced vital capacity)..
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1407.1 FEV (forced expiratory vol)..
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1408 8. LIVER FUNCTION TESTS..........
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9. RADIOLOGIC EVALUATION:
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BONE SCAN:
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1409 BONE SCAN....................
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1409.2 VASCULAR INVASION...........
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1409.3 MEDIASTINAL LYMPH NODES.....
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1409.4 SIZE OF DOMINANT TUMOR (mm).
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1409.5 NUMBER OF TUMORS............
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1409.6 EVIDENCE OF METASTASIS......
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CT SCAN OF CHEST:
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1410 CT SCAN OF CHEST.............
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1410.2 VASCULAR INVASION...........
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1410.3 MEDIASTINAL LYMPH NODES.....
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1410.4 SIZE OF DOMINANT TUMOR (mm).
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1410.5 NUMBER OF TUMORS............
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1410.6 EVIDENCE OF METASTASIS......
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CT SCAN OF BRAIN:
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1411 CT SCAN OF BRAIN.............
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1411.2 VASCULAR INVASION...........
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1411.3 MEDIASTINAL LYMPH NODES.....
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1411.4 SIZE OF DOMINANT TUMOR (mm).
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1411.5 NUMBER OF TUMORS............
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1411.6 EVIDENCE OF METASTASIS......
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MRI SCAN OF CHEST:
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1412 MRI SCAN OF CHEST............
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1412.2 VASCULAR INVASION...........
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1412.3 MEDIASTINAL LYMPH NODES.....
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1412.4 SIZE OF DOMINANT TUMOR (mm).
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1412.5 NUMBER OF TUMORS............
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1412.6 EVIDENCE OF METASTASIS......
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MRI SCAN OF BRAIN:
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1413 MRI SCAN OF BRAIN............
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1413.2 VASCULAR INVASION...........
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1413.3 MEDIASTINAL LYMPH NODES.....
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1413.4 SIZE OF DOMINANT TUMOR (mm).
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1413.5 NUMBER OF TUMORS............
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1413.6 EVIDENCE OF METASTASIS......
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PET SCAN:
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1414 PET SCAN.....................
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1414.2 VASCULAR INVASION...........
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1414.3 MEDIASTINAL LYMPH NODES.....
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1414.4 SIZE OF DOMINANT TUMOR (mm).
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1414.5 NUMBER OF TUMORS............
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1414.6 EVIDENCE OF METASTASIS......
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X-RAY OF CHEST:
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1415 X-RAY OF CHEST...............
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1415.2 VASCULAR INVASION...........
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1415.3 MEDIASTINAL LYMPH NODES.....
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1415.4 SIZE OF DOMINANT TUMOR (mm).
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1415.5 NUMBER OF TUMORS............
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1415.6 EVIDENCE OF METASTASIS......
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10. PRE-OP LYMPH NODE MAPPING:
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1416 HIGHEST MEDIASTINAL (level 1)
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1416.1 UPPER PARATRACHEAL (level 2).
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1416.2 PREVASCULAR AND RETROTRACHEAL (level 3)...................
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1416.3 LOWER PARATRACHEAL (level 4).
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1416.8 PULMONARY LIGAMENT (level 9).
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EMPHYSEMA...................: NA, test not performed
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VASCULAR INVASION...........: NA, test not performed
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MEDIASTINAL LYMPH NODES.....: NA, test not performed
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SIZE OF DOMINANT TUMOR (mm).: Test not performed
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NUMBER OF TUMORS............: Test not performed
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EVIDENCE OF METASTASIS......: NA, test not performed
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EMPHYSEMA...................: Not documented
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VASCULAR INVASION...........: Not documented
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MEDIASTINAL LYMPH NODES.....: Not documented
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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