|
Eligible participant has to fullfill all of the following items | / / / / / / / |
|
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
|
Date of signing the informed consent | 2024-2-8 |
|
Date of birth | 1982-2-23 yyyy-mm-dd |
|
Age | 41 Years |
|
Education background | Middle school
|
|
Occupation | Famer
|
|
Other (Description) | -- |
10 小时 |
|
无 |
|
|
Number of pregnancy | 5 次 |
|
Number of delivery | 1 次 |
|
If has delivery history, select following items | |
|
partus maturus | 1 次 |
|
premature delivery | 0 次 |
|
abortion | 4 次 |
|
Last pregnancy | 不详 yyyy-mm-dd |
|
Average times of menstrual onset a year | 12 次/年 |
|
Average menstrual cycle | 4 天(days) |
|
Menarche time | 15 岁(years) |
|
The time of last Menstruation | 2024-1-12 年、月、日(yyyy-mm-dd) |
|
The time of menstrual onset before the last one | 不详 年、月、日(yyyy-mm-dd) |
小三阳 剖宫产 |
|
14年前小三阳、 年/月/日（yyyy-mm-dd） |
|
|
Namy of the drug to be allergied | 无 |
|
Vulva | Normal
|
|
Description in detail for abnormal | -- |
|
Vagina | Not examined
|
|
Description in detail for abnormal | 可见暗红色血迹 |
|
Uterine neck | Normal
|
|
Description in detail for abnormal | -- |
|
Corpus uteri | Abnormal
|
|
Description in detail for abnormal | 偏右侧 |
|
Adnexa uteri | |
|
Left side | Abnormal
|
|
Description in detail for abnormal | 10*8*8cm包块，压痛。 |
|
Right side | Normal
|
|
Description in detail for abnormal | -- |
|
Weight | 65 kg |
|
Hight | 1600 mm |
|
Systolic pressure (SP) | 160 mmHg |
|
Diastolic pressure | 98 mmHg |
|
Temperature | 36.4 degree Celsius |
|
Pulse rate | 66 次/分 |
|
Breath frequency | 17 次/分 |
|
Doctor signature | 刘义彬 |
|
Date | 2024-2-8 yyyy-mm-dd |
|
WBC | 9.5 ×109 /L |
|
NEUT% | 88.16 % |
|
LY% | 8.59 % |
|
MONO％ | 2.92 ％ |
|
RBC | 4.37 ×10^12 /L |
|
HGB | 137 g/L |
|
PLT | 287 ×10^9 /L |
|
Researcher signature | 刘义彬 |
|
Date | 2024-2-8 yyyy-mm-dd |
|
Acidity and allkalinity | |
|
pH value | -- |
|
Urine protein | |
|
Urine red cell | |
|
Urine WBC | |
|
Urine glucos | |
|
Urine Bilirubin | |
|
Urine HCG | |
|
KET | |
|
SG | -- |
|
UBG | |
|
NIT | |
|
Date of test | 未查 yyyy-mm-dd |
|
Date of test | 2024-2-8 yyyy-mm-dd |
|
K | 未查 mmol/L |
|
Na | -- mmol/L |
|
Cl | -- mmol/L |
|
Ca | -- mmol/L |
|
P | -- mmol/L |
|
Date of examination | 2024-2-8 yyyy-mm-dd |
|
Prothrombin time | 11.4 秒 |
|
Thrombin time (TT) | 13.7 秒 |
|
Activated partial thromboplastin time (APTT) | 28.4 秒 |
|
Fibrinogen (FIB) | 3.23 g/L |
|
ALT | 21.9 IU/L |
|
AST | 22.0 IU/L |
|
GGT | 13.0 U/L |
|
Serum bilirubin | 16.60 μmol/L |
|
Indirect bilirubin | 12.80 umol/L |
|
Direct bilirubin | 3.80 umol/L |
|
Serum albumin | 45.8 g/L |
|
Serum globulin | 32.5 g/L |
|
Serum total protein | 78.3 g/L |
|
Date of test | 2024-2-8 yyyy-mm-dd |
Positive
|
|
|
Date of test | 2024-2-8 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-2-8 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-2-8 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-2-8 yyyy-mm-dd |
|
SCr | 59.0 μmol/L |
|
Blood urea | 3.80 mmol/L |
|
Blood uric acid | 214.0 μmol/L |
|
Date of test | 2024-2-8 yyyy-mm-dd |
|
D-dimer value | 0.09 ug/mL |
|
Date of test | 2024-2-8 |
|
Urine pregnancy test | Not tested
|
|
Blood HCG concentration | -- mIU/mL |
|
Date of test | 2024-2-8 yyyy-mm-dd |
|
Size of the ulcer | 3.8*3.96*3.78 cm*cm |
|
Uterine echo distribution | Even
|
|
Endometrial thickness | 0.45 mm |
|
Left ovary size | 未描述 cm ×cm |
|
Shape of Left ovary | |
|
Size of the Ovarian cyst | 子宫后方12.86*9.59*7.2cm，混合性包块，内为强回声，部分为暗区，有的暗区内见短条状强回声 |
|
Right ovary size | 未描述 cm ×cm |
|
Shape of right ovary | |
|
Size of Ovarian cyst | -- |
|
Description of other abnormal findings | -- |
|
Diagnosis of the Ultrasound B | 卵巢肿物 |
|
Doctor signature | 刘义彬 |
|
Date of examination | 2024-2-8 yyyy-mm-dd |
|
Pain Visual Analogue Score | Very pain
|
|
PH | 7.385 |
|
PCO2 | 36.0 mmHg |
|
P02 | 82.6 mmHg |
|
SO2 | 95.4 ％ |
|
HCO3 | 21.6 mmol/l |
|
SBE | -3.4 mmol/l |
|
LAC | 1.77 mmol/L |
|
Date of examination | 2024-2-8 (yyyy-mm-dd) |
左侧附件 |
|
12*10*8 cm |
|
逆时针540度 ° |
|
| / | |
刘义彬 |
|
2024-2-8 |
|
D-dimer value | 0.56 ug/mL |
|
Date of test | 2024-2-9 |
|
Body temperature | 36.8 ℃ |
|
Systolic pressure (SP) | 未查 mmHg |
|
Diastolic pressure (DP) | 未查 mmHg |
|
Heart Rate, HR | 82 次/分 |
|
Pulse | 82 次/秒 |
|
WBC | 7.3 ×109 /L |
|
NEUT% | 62.81 % |
|
LY% | 25.92 % |
|
MONO％ | 10.33 ％ |
|
RBC | 3.71 ×10^12 /L |
|
HGB | 121 g/L |
|
PLT | 241 ×10^9 /L |
|
Date | 20234-2-9 yyyy-mm-dd |
| / | |
|
Pain Visual Analogue Score | Occasionally very slight pain
|
|
sample collection | |
|
Volume | ml |
|
Time of collection | yyyy-mm-dd-hh-min. |
|
Label Number of the sample |
|
|
Date received at DCC | yyyymmdd |
|
Report type | |
|
Name of this event |
|
|
SAE start date | yyyymmdd |
|
SAE stop date | yyyymmdd |
|
Was this an unanticipated adverse event | |
|
Attribution to Study Drug | |
|
Outcome Type(check all that apply) | |
|
Recovery Description: (check only one) | |
|
Please provide a brief narrative of the SAE occurrence below |
|
|
Name of the recorder |
|
|
Data | yyyymmdd |
|
Site Investigator’s signature |
|
|
Data | yyyymmdd |