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Neurooncology Data Form

Neurooncology Data Form

Neurooncology Data Form

Neurooncology Data Form

Personnel Details Clinical Presentation Clinical Examination Blood Investigations Radiology Surgical Management Radiation Therapy Chemotherapy Histopathology Neuropathological Diagnosis Outcome at Discharge Follow Up

Section A - Personnel Details

Unique ID:

Institute Name:

IP/OP Number:

First Name:

Last Name:

Age:

Gender:

Address Street:

Address PIN Code:

Address State:

Address Country:

Contact Number:

Email:

Informant:

Mode of Arrival:

Education:

Occupational Status:

Income:

Marital Status:

Section-B Management: Clinical Presentation

Headache:

Seizures:

Nausea and Vomiting:

Visual Disturbances:

Hearing Loss:

Tinnitus:

Cognitive Changes:

Motor Symptoms:

Sensory Deficits:

Speech and Language:

Balance and Coordination:

Endocrine Dysfunction:

Fatigue and Weakness:

Behavioral Changes:

Dizziness or Vertigo:

Consciousness Disturbance:

Difficulty swallowing (dysphagia):

Facial numbness:

Facial weakness:

Involuntary movements or tremors:

Section C: Clinical Examination

Blood pressure:

Heart rate:

Respiratory rate:

Temperature:

Level of consciousness (alertness):

Orientation (time):

Orientation (place):

Orientation (person):

Short-term memory:

Long-term memory:

Language fluency:

Language comprehension:

Language repetition:

Vision (acuity):

Vision (fields):

Fundoscopy for papilledema:

Pupillary response:

Extraocular movements:

Facial symmetry and strength:

Hearing function:

Vestibular function:

Swallowing reflex:

Gag reflex:

Tongue movement:

Speech articulation:

Muscle bulk:

Muscle tone:

Muscle strength:

Deep tendon reflexes:

Pathological reflexes (e.g., Babinski sign):

Gait:

Posture:

Light touch sensation:

Pain sensation:

Temperature sensation:

Vibration sensation:

Proprioception (sense of position):

Finger-to-nose coordination:

Heel-to-shin coordination:

Rapid alternating movements:

Ataxic gait:

Tandem walking (coordination):

Bladder control:

Bowel control:

Papilledema (via fundoscopy):

Optic atrophy (via fundoscopy):

Retinal abnormalities (via fundoscopy):

Bulging fontanelle (in infants):

Galactorrhea:

Gynecomastia:

Acromegaly:

Assessment of mood:

Assessment of behavior:

Assessment of higher cognitive functions:

Section D: Investigations at Admission - Blood

Hemoglobin (gm/dL):

Total leucocyte count (/mm3):

Blood Sugar Random (mg/dL):

Blood Sugar Fasting (mg/dL):

Blood Sugar PP (mg/dL):

Platelets (/mm3):

Cerebrospinal fluid cytology:

Blood or cerebrospinal fluid test:

Section E: Radiology

Date of CT:

CT Contrast:

CT Findings:

Date of MRI:

Time of MRI:

MRI Contrast:

MRI details:

MRI Findings:

Date of PET:

Time of PET:

PET Contrast:

eFAST:

Chest X-ray:

Cervical spine X-ray:

Dorsal spine X-ray:

Lumbar spine X-ray:

Pelvis X-ray:

Long bone x-rays:

CT cervical spine:

CT chest:

CT abdomen:

CT pelvis:

MRI brain:

MRI Spine:

DSA:

Section-F Surgical Management

Treatment:

Mode of Therapy:

Initial Surgery:

Date of Surgery:

Type of Surgery:

Primary Site:

Extent of Surgery:

Tumour Location:

Operation Approach:

Intraoperative Assistive Technologies:

Extent of Tumour Resection:

Blood Loss Volume:

Secondary Operation:

Tumour Characteristics: Multiplicity:

Tumour Characteristics: Laterality:

Tumour Characteristics: Tumor Location:

CSF Drainage:

Complication During the Whole Treatment:

Pattern of Recurrence at Investigation:

Any Drug Therapy During the Whole Treatment:

Any Therapy During the Whole Treatment:

Section-G Management: Radiation Therapy

Start Date:

End Date:

Dose:

Fractions:

Fields:

Stereotactic Radiosurgery:

Completed:

If not completed, Due To:

Section-H Management: Chemotherapy

Concurrent Chemotherapy + RT:

Start Date:

End Date:

Drugs Used:

Dose Reduction:

Completed:

If not completed, Due To:

Toxicity:

Section I Histopathology

WHO grade (according to WHO 2016 classification of CNS tumours):

Section J Neuropathological Diagnosis including Molecular and Genetic Markers

Pathology Report Date:

Site of Tumor:

Laterality of Tumor:

Histological Tumor Type:

Metastasis, Primary Site:

Tumor Size (L, W & H):

L:

W:

H:

Tumor Type:

WHO Tumor Grade:

Marker Testing Method: Test Type:

1p19q Analysis:

MGMT Methylation:

Ki-67 Analysis:

IDH1 Analysis:

p53 Analysis:

BRAF-KIAA1549 Analysis:

H3F3A K27 Analysis:

H3F3A G34 Analysis:

FGFR1 Analysis:

ATRX:

BRAF:

IDH1 Codon 132:

IDH2 Codon 172:

EGFR:

Section K Outcome at discharge

Outcome at discharge:

Outcome date:

Survival Status at discharge:

Discharge Destination Hospital:

Neurological Examination:

Endocrine Examination:

Postoperative Karnofsky Scale:

Postoperative ECOG Performance Status:

MRI:

CT:

Section L Follow Up

Date of Follow-Up:

Status:

Evidence of Recurrence:

Progression:

Stable Disease:

Patient Condition While Followed-Up:

Treatment After Discharge:

Symptoms and Physical Signs:

Follow-Up Imaging:

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