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PHỤ LỤC 1

BỆNH ÁN MẪU

1. Phần hành chánh


		Họ và tên (viết tắt):
		Năm sinh:
		Số hồ sơ:
		2. Lý do nhập viện
Tiểu khó:	có	không
Tiểu máu:	có	không
Bí tiểu:	có	không
Tái khám định kỳ	có	không
PSA/ máu tăng	có	không
Phát hiện TTL lớn qua siêu âm: có không
Lý do khác:	có	không
3. Tiền căn bệnh
Tăng huyết áp:	có	không
Thiểu năng vành:	có	không
Tiểu đường:	có	không
Lao phổi:	có	không
Các bệnh khác:	có	không
4. Tiền căn gia đình
Tăng huyết áp:	có	không
Thiểu năng vành:	có	không
Tiểu đường:	có	không
Lao phổi:	có	không
Các bệnh khác:	có	không

Các cơ quan khác:
7.5.  	Siêu âm qua trực tràng Kích thước: Nhân ung thư:	có	không
	Xâm lấn vỏ bọc:	có	không
	Túi tinh:	có	không
7.6.    	Sinh thiết tuyến tiền liệt Số mẫu sinh thiết Kết quả GPB: Số mẫu (+): Điểm số Gleason:
7.7.	X-quang phổi:
7.8.	Đo ECG:
7.9.   	MSCT scan: Xâm lấn mô xung quanh Xâm lấn túi tinh: Di căn hạch	có	không
 	Di căn gan: Tình trạng thận:	có	không
7.10.   	Chụp cộng hưởng từ: Xâm lấn mô xung quanh Xâm lấn túi tinh: Di căn hạch	có	không
 	Di căn gan: Tình trạng thận:	có	không
7.11.	Xạ hình xương: