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Eligible participant has to fullfill all of the following items | / / / / / / / |
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Anyone with one of following items or more should be excluded: | / / / / / / / / / / |
- General information
- Medical history
- Physical examination
- Blood Routine Tests
- Urine Routine Test
- Blood Electrolytes Tests
- Coagulation Function Tests
- Serum Liver Function Tests
- HBV/HCV/HIV/Syphilis Markers Test
- Renel Function Test
- D-dimer
- hCG Test
- Image Examinations
- Visual Analogue Scale
- Blood Gas Analysis
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Date of signing the informed consent | 2018-5-28 |
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Date of birth | 1964-06-13 yyyy-mm-dd |
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Age | 53 Years |
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Education background | Middle school
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Occupation | Famer
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Other (Description) | 2018-5-28 |
4天 小时 |
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活动后 |
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Number of pregnancy | 5 次 |
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Number of delivery | 3 次 |
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If has delivery history, select following items | |
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partus maturus | 3 次 |
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premature delivery | -- 次 |
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abortion | 2 次 |
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Last pregnancy | 26年前 yyyy-mm-dd |
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Average times of menstrual onset a year | 12 次/年 |
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Average menstrual cycle | 30 天(days) |
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Menarche time | 14 岁(years) |
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The time of last Menstruation | 51岁 年、月、日(yyyy-mm-dd) |
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The time of menstrual onset before the last one | 不详 年、月、日(yyyy-mm-dd) |
-- |
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-- 年/月/日（yyyy-mm-dd） |
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Namy of the drug to be allergied | -- |
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Vulva | Normal
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Description in detail for abnormal | -- |
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Vagina | Normal
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Description in detail for abnormal | -- |
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Uterine neck | Normal
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Description in detail for abnormal | -- |
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Corpus uteri | Normal
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Description in detail for abnormal | -- |
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Adnexa uteri | |
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Left side | Normal
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Description in detail for abnormal | -- |
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Right side | Abnormal
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Description in detail for abnormal | 6*5cm肿物 |
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Weight | 72.5 kg |
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Hight | 1570 mm |
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Systolic pressure (SP) | 124 mmHg |
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Diastolic pressure | 75 mmHg |
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Temperature | 36.5 degree Celsius |
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Pulse rate | 104 次/分 |
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Breath frequency | 20 次/分 |
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Doctor signature | 刘义彬 |
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Date | 2018-5-28 yyyy-mm-dd |
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WBC | 无法追溯 ×109 /L |
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NEUT% | 无法追溯 % |
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LY% | 无法追溯 % |
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MONO％ | 无法追溯 ％ |
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RBC | 无法追溯 ×10^12 /L |
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HGB | 无法追溯 g/L |
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PLT | 无法追溯 ×10^9 /L |
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Researcher signature | 无法追溯 |
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Date | 无法追溯 yyyy-mm-dd |
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Acidity and allkalinity | |
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pH value | 无法追溯 |
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Urine protein | |
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Urine red cell | |
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Urine WBC | |
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Urine glucos | |
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Urine Bilirubin | |
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Urine HCG | |
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KET | |
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SG | 无法追溯 |
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UBG | |
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NIT | |
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Date of test | 无法追溯 yyyy-mm-dd |
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Date of test | 2018-5-28 yyyy-mm-dd |
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K | 3.42 mmol/L |
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Na | 138.9 mmol/L |
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Cl | -- mmol/L |
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Ca | 1.2 mmol/L |
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P | -- mmol/L |
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Date of examination | -- yyyy-mm-dd |
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Prothrombin time | -- 秒 |
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Thrombin time (TT) | -- 秒 |
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Activated partial thromboplastin time (APTT) | -- 秒 |
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Fibrinogen (FIB) | -- g/L |
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ALT | -- IU/L |
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AST | -- 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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Date of test | -- yyyy-mm-dd |
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Date of test | -- yyyy-mm-dd |
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Date of test | -- yyyy-mm-dd |
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Date of test | -- yyyy-mm-dd |
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Date of test | -- yyyy-mm-dd |
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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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Date of test | -- yyyy-mm-dd |
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D-dimer value | -- ug/mL |
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Date of test | -- |
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Urine pregnancy test | Not tested
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Blood HCG concentration | -- mIU/mL |
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Date of test | -- yyyy-mm-dd |
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Size of the ulcer | -- cm*cm |
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Uterine echo distribution | |
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Endometrial thickness | -- mm |
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Left ovary size | -- cm ×cm |
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Shape of Left ovary | |
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Size of the Ovarian cyst | -- |
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Right ovary size | -- cm ×cm |
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Shape of right ovary | |
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Size of Ovarian cyst | -- |
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Description of other abnormal findings | -- |
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Diagnosis of the Ultrasound B | -- |
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Doctor signature | -- |
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Date of examination | -- yyyy-mm-dd |
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Pain Visual Analogue Score | Rather pain tolerable
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PH | 7.362 |
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PCO2 | 41.4 mmHg |
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P02 | 143.3 mmHg |
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SO2 | -- ％ |
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HCO3 | -- mmol/l |
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SBE | -- mmol/l |
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LAC | 1.36 mmol/L |
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Date of examination | 2018-5-28 (yyyy-mm-dd) |
右侧输卵管 |
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6*5*5 cm |
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逆时针7周 ° |
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刘义彬 |
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2018-5-28 |
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D-dimer value | -- ug/mL |
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Date of test | -- |
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Body temperature | 36.8 ℃ |
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Systolic pressure (SP) | 128 mmHg |
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Diastolic pressure (DP) | 80 mmHg |
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Heart Rate, HR | 88 次/分 |
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Pulse | 88 次/秒 |
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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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Date | -- yyyy-mm-dd |
| / | |
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Pain Visual Analogue Score | Occasionally very slight pain
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sample collection | Collected
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Volume | 1 ml |
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Time of collection | 2018-5-28 yyyy-mm-dd-hh-min. |
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Label Number of the sample | -- |
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Date received at DCC | -- yyyymmdd |
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Report type | |
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Name of this event | -- |
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SAE start date | -- yyyymmdd |
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SAE stop date | -- yyyymmdd |
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Was this an unanticipated adverse event | |
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Attribution to Study Drug | |
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Outcome Type(check all that apply) | |
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Recovery Description: (check only one) | |
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Please provide a brief narrative of the SAE occurrence below | -- |
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Name of the recorder | -- |
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Data | -- yyyymmdd |
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Site Investigator’s signature | -- |
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Data | -- yyyymmdd |