- Screening
- Baseline
- In the process of the treatment
- At the end of the treatment
- Follow-up 1
- Follow-up 2
- Follow-up 3
- Management system of participants
- Speciman management system
- Data management system
- ADR/ADE management system
- Madicine management system
- Instruments management system
- SOPs
- Research team
- Design, Methods
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Eligible participant has to fullfill all of the following items | / / / / / / |
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Date | yyyy-mm-dd |
- General information
- Physical examination
- Blood Routine Tests
- Urine and Stool Routine Tests
- Glucose test
- Serum Liver Function Tests
- Renel Function Test
- Heat Function Examination
- Image Examinations
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Gender | Male
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Your age | 46 岁(years) |
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Date of birth: | 1973-10-22 yyyy-mm-dd |
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Nationality | Han
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Marriage history | |
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Pulse rate | 次/分 |
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Breath frequency | 次/分 |
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Systolic pressure (SP) | mmHg |
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Diastolic pressure | mmHg |
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Did you experienced any drug allergy? | No
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Namy of the drug to be allergied |
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Date of drug allergy happened | yyyy-mm-dd/mm-dd |
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Doctor signature |
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Date | yyyy-mm-dd |
间断多饮多尿、体重下降24年，右足破溃1月，加重1天。患者于24年前无明显诱因出现多饮、多尿、体重下降，诊断为2型糖尿病，口服二甲双胍片0.5日二次，格列苯脲2.5毫克日二次，2年前口服药失效，血糖升高，就诊平泉县医院更改为精蛋白重组人胰岛素14单位早晚餐前15分钟皮下注射，口服二甲双胍0.5日三次，阿卡波糖100mg日三次，血糖控制可，1月前右足第三趾破溃，出现混合坏疽，蔓延足心。 |
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Wagner grade | |
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Signature of the doctor |
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Date of examination | 2019-12-21 yyyy-mm-dd |
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WBC | 14.2 ×109 /L |
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NEUT% | 79 % |
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LY% | 12.8 % |
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MONO％ | 5.9 ％ |
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RBC | 3.33 ×10^12 /L |
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HGB | 101 g/L |
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PLT | 413 ×10^9 /L |
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Date | 2019-12-21 yyyy-mm-dd |
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Acidity and allkalinity | Acidity
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pH value | 5.5 |
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Urine protein | Negative
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Urine red cell | Negative
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Urine WBC | Negative
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Urine glucos | Positive+++
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Urine Bilirubin | Negative
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Urine HCG | Negative
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KET | Negative
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SG | 1.01 |
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UBG | Negative
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NIT | Negative
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Date of test | 2019-12-21 yyyy-mm-dd |
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Fasting blood glucos concentration | 19.2 mmol/L |
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Two hours after breakfast | mmol/L |
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Two hours after lunch | mmol/L |
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Two hours after dinner | mmol/L |
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Date of test | yyyy-mm-dd |
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CRP | mg/L |
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Date of test | 2019-12-21 yyyy-mm-dd |
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Fib | g/L |
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t-PA | ug/L |
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PAI-1 | ug/L |
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Date of test |
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HbA1c | % |
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Date of test | yyyy-mm-dd |
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Signature of the doctor |
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Date of examination | yyyy-mm-dd |
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ALT | 11 IU/L |
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AST | 11 IU/L |
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γ-Glutamyltransferase | 84 IU/L |
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Serum bilirubin | 3.3 μmol/L |
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Indirect bilirubin | 1.7 umol/L |
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Direct bilirubin | 1.6 umol/L |
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Serum albumin | 23 g/L |
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Serum total protein | 61 g/L |
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Date of test | 2019-12-21 yyyy-mm-dd |
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Blood uric acid | 222 μmol/L |
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SCr | 72 μmol/L |
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Blood urea | 6.5 mmol/L |
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Date of test | 2019-12-21 yyyy-mm-dd |
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Ultrasonic echocardiography, UCG | |
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Description in detail for abnormal |
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Date of examination | yyyy-mm-dd |
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AST | U |
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LDH | IU |
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Lactic dehydrogenase isoenzyme | |
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α-HBDH | U/L |
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Creatine Kinase, CK | U/L |
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Creatine kinase isoenzyme, CKMB | U/L |
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Date of tests | yyyy-mm-dd |
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Signature of the doctor |
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yyyy-mm-dd |
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ALT | IU/L |
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AST | IU/L |
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AST/ALT |
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γ-Glutamyltransferase | IU/L |
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GGT | U/L |
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Serum bilirubin | μmol/L |
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Indirect bilirubin | umol/L |
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Direct bilirubin | umol/L |
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Serum albumin | g/L |
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Serum globulin | g/L |
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Serum total protein | g/L |
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A/G |
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Date of test | yyyy-mm-dd |
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BUN | 8mmol/L |
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SCr | μmol/L |
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Blood urea | mmol/L |
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Blood uric acid | μmol/L |
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Cr |
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Blood endogenous creatinine clearance | ml·s-1/m*2 |
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BUN/Cr |
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Date of test | yyyy-mm-dd |
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ALT | IU/L |
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AST | IU/L |
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AST/ALT |
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γ-Glutamyltransferase | IU/L |
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Serum bilirubin | μmol/L |
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Indirect bilirubin | umol/L |
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Direct bilirubin | umol/L |
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Serum albumin | g/L |
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Serum globulin | g/L |
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Serum total protein | g/L |
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A/G |
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Date of test | yyyy-mm-dd |
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BUN | 8mmol/L |
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SCr | μmol/L |
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Blood urea | mmol/L |
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Blood uric acid | μmol/L |
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Cr |
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Date of test | yyyy-mm-dd |
- Management for Progress
- Blood Routine Tests
- Glucose test
- Liver Function Tests
- Renel Function Test
- Heat Function Examination
- Image Examinations
- Health Relative Quality of Life
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Is there any additional combination drug? | |
次 |
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WBC | ×109 /L |
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NEUT% | % |
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LY% | % |
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MONO％ | ％ |
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RBC | ×10^12 /L |
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HGB | g/L |
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PLT | ×10^9 /L |
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Researcher signature |
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Date | yyyy-mm-dd |
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HbA1c | % |
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Date of test | yyyy-mm-dd |
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Blood glucose | mmol/L |
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LAGE |
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MAGE |
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SDBG |
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MODD |
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LBGI |
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Date of test | yyyy-mm-dd |
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Daily usage of insulin | IU |
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Date of detection | yyyy-mm-dd |
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ALT | IU/L |
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AST | IU/L |
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AST/ALT |
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γ-Glutamyltransferase | IU/L |
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Serum bilirubin | μmol/L |
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Indirect bilirubin | umol/L |
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Direct bilirubin | umol/L |
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Serum albumin | g/L |
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Serum globulin | g/L |
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Serum total protein | g/L |
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A/G |
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Date of test | yyyy-mm-dd |
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BUN | 8mmol/L |
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SCr | μmol/L |
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Blood urea | mmol/L |
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Blood uric acid | μmol/L |
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Cr |
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Date of test | yyyy-mm-dd |
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Ultrasonic echocardiography, UCG | |
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Description in detail for abnormal |
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Date of examination | yyyy-mm-dd |
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AST | U |
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LDH | IU |
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Lactic dehydrogenase isoenzyme | |
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α-HBDH | U/L |
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Creatine Kinase, CK | U/L |
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Creatine kinase isoenzyme, CKMB | U/L |
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Date of tests | yyyy-mm-dd |
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Before primary wounding | 分 |
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Now (Current at moment) | 分 |
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Signature of the doctor |
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Date of examination | yyyy-mm-dd |
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Whether got the informed consent? | |
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Date of sign the informed consent | xx年xx月xx日 |
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Adverse events | |
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Name of the adverse event |
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Date of starting | yyyy-mm-dd |
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Ending time | yyyy-mm-dd |
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Does it continues to now | |
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Severity | |
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Corelation with the study drug | |
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The method of treating the drug | |
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The outcome | |
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Is it sevious adverse event? | |
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Did it resulted in stoped the study? | |
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Possible reason of causing the adverse event | |
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Person who report the adverse event |
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Time of the reporting | yyyy-mm-dd-hh-min. |