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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 | 2018-11-24 |
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Date of birth | 2006-11-01 yyyy-mm-dd |
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Age | 12 Years |
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Education background | Middle school
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Occupation | Other
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Other (Description) | 学生 |
12 小时 |
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无 |
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Number of pregnancy | -- 次 |
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Number of delivery | -- 次 |
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If has delivery history, select following items | |
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partus maturus | -- 次 |
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premature delivery | -- 次 |
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abortion | -- 次 |
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Last pregnancy | -- yyyy-mm-dd |
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Average times of menstrual onset a year | 未月经来潮 次/年 |
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Average menstrual cycle | -- 天(days) |
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Menarche time | -- 岁(years) |
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The time of last Menstruation | -- 年、月、日(yyyy-mm-dd) |
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The time of menstrual onset before the last one | -- 年、月、日(yyyy-mm-dd) |
无 |
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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 | Not examined
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Description in detail for abnormal |
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Uterine neck | Not examined
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Description in detail for abnormal |
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Corpus uteri | Not examined
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Description in detail for abnormal |
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Adnexa uteri | |
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Left side | Not examined
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Description in detail for abnormal |
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Right side | Not examined
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Description in detail for abnormal |
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Weight | 58 kg |
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Hight | 1600 mm |
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Systolic pressure (SP) | 102 mmHg |
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Diastolic pressure | 64 mmHg |
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Temperature | 36.5 degree Celsius |
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Pulse rate | 92 次/分 |
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Breath frequency | 23 次/分 |
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Doctor signature | 刘义彬 |
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Date | 2018-11-24 yyyy-mm-dd |
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WBC | 8.5 ×109 /L |
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NEUT% | 61.90 % |
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LY% | 29.60 % |
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MONO％ | 6.80 ％ |
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RBC | 4.51 ×10^12 /L |
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HGB | 132 g/L |
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PLT | 244 ×10^9 /L |
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Researcher signature | 刘义彬 |
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Date | 2018-11-24 yyyy-mm-dd |
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Acidity and allkalinity | Acidity
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pH value | 6.0 |
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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 | Negative
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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 | 1.020 |
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UBG | Negative
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NIT | Negative
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Date of test | 2018-11-25 yyyy-mm-dd |
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Date of test | 2018-11-25 yyyy-mm-dd |
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K | 4.06 mmol/L |
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Na | 142.1 mmol/L |
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Cl | 104.0 mmol/L |
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Ca | 2.44 mmol/L |
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P | 1.57 mmol/L |
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Date of examination | 2018-11-25 yyyy-mm-dd |
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Prothrombin time | 12.0 秒 |
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Thrombin time (TT) | 14.9 秒 |
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Activated partial thromboplastin time (APTT) | 31.1 秒 |
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Fibrinogen (FIB) | 2.91 g/L |
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ALT | 8.3 IU/L |
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AST | 13.7 IU/L |
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GGT | 11.0 U/L |
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Serum bilirubin | 8.7 μmol/L |
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Indirect bilirubin | 5.10 umol/L |
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Direct bilirubin | 3.60 umol/L |
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Serum albumin | 47.9 g/L |
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Serum globulin | 26.0 g/L |
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Serum total protein | 73.9 g/L |
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Date of test | 2018-11-25 yyyy-mm-dd |
Negative
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Date of test | 2018-11-25 yyyy-mm-dd |
Negative
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Date of test | 2018-11-25 yyyy-mm-dd |
Negative
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Date of test | 2018-11-25 yyyy-mm-dd |
Negative
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Date of test | 2018-11-25 yyyy-mm-dd |
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SCr | 53.0 μmol/L |
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Blood urea | 4.90 mmol/L |
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Blood uric acid | 329.0 μmol/L |
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Date of test | 2018-11-25 yyyy-mm-dd |
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D-dimer value | 0.25 ug/mL |
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Date of test | 2018-11-25 |
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Urine pregnancy test | Not tested
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Blood HCG concentration | 未查 mIU/mL |
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Date of test | -- yyyy-mm-dd |
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Size of the ulcer | 2.5*2.47*1.83 cm*cm |
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Uterine echo distribution | Even
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Endometrial thickness | 4.3 mm |
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Left ovary size | 1.7*1.59 cm ×cm |
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Shape of Left ovary | Normal
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Size of the Ovarian cyst | -- |
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Right ovary size | 3.6*3.13*2.96 cm ×cm |
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Shape of right ovary | Ovarian cyst
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Size of Ovarian cyst | 2.77cm |
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Description of other abnormal findings | -- |
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Diagnosis of the Ultrasound B | 右卵巢畸胎瘤 |
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Doctor signature | 刘义彬 |
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Date of examination | 2018-11-25 yyyy-mm-dd |
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Pain Visual Analogue Score | Very pain
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PH | 7.369 |
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PCO2 | 38.6 mmHg |
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P02 | 56.1 mmHg |
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SO2 | 91.4 ％ |
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HCO3 | 21.9 mmol/l |
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SBE | -3.0 mmol/l |
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LAC | 0.98 mmol/L |
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Date of examination | 2018-11-24 (yyyy-mm-dd) |
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D-dimer value | 未查 ug/mL |
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Date of test | 未查 |
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Body temperature | 36.5 ℃ |
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Systolic pressure (SP) | 102 mmHg |
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Diastolic pressure (DP) | 64 mmHg |
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Heart Rate, HR | 92 次/分 |
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Pulse | 92 次/秒 |
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WBC | 6.50 ×109 /L |
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NEUT% | 56.40 % |
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LY% | 31.10 % |
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MONO％ | 9.30 ％ |
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RBC | 4.38 ×10^12 /L |
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HGB | 131 g/L |
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PLT | 220 ×10^9 /L |
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Date | 2018-11-27 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 | 2018-11-24 yyyy-mm-dd-hh-min. |
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Label Number of the sample | 2100619 |
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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 |