|
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 | 2024-2-25 |
|
Date of birth | 1978-12-26 yyyy-mm-dd |
|
Age | 45 Years |
|
Education background | University
|
|
Occupation | Doctor
|
|
Other (Description) | -- |
间断1个月 小时 |
|
无 |
|
|
Number of pregnancy | 1 次 |
|
Number of delivery | 1 次 |
|
If has delivery history, select following items | |
|
partus maturus | 1 次 |
|
premature delivery | - 次 |
|
abortion | - 次 |
|
Last pregnancy | 不详 yyyy-mm-dd |
|
Average times of menstrual onset a year | 13 次/年 |
|
Average menstrual cycle | 7 天(days) |
|
Menarche time | 15 岁(years) |
|
The time of last Menstruation | 2024-2-20 年、月、日(yyyy-mm-dd) |
|
The time of menstrual onset before the last one | 不详 年、月、日(yyyy-mm-dd) |
-- |
|
-- 年/月/日（yyyy-mm-dd） |
|
|
Namy of the drug to be allergied | 无 |
|
Vulva | Normal
|
|
Description in detail for abnormal | 2024-2-25 |
|
Vagina | Normal
|
|
Description in detail for abnormal | 2024-2-25 |
|
Uterine neck | Normal
|
|
Description in detail for abnormal | 2024-2-25 |
|
Corpus uteri | Normal
|
|
Description in detail for abnormal | 2024-2-25 |
|
Adnexa uteri | |
|
Left side | Abnormal
|
|
Description in detail for abnormal | 增厚 |
|
Right side | Abnormal
|
|
Description in detail for abnormal | 可触及5cm包块 |
|
Weight | 63 kg |
|
Hight | 1630 mm |
|
Systolic pressure (SP) | 117 mmHg |
|
Diastolic pressure | 76 mmHg |
|
Temperature | 36.6 degree Celsius |
|
Pulse rate | 88 次/分 |
|
Breath frequency | 22 次/分 |
|
Doctor signature | 刘义彬 |
|
Date | 2024-2-25 yyyy-mm-dd |
|
WBC | 4.90 ×109 /L |
|
NEUT% | 59.88 % |
|
LY% | 30.50 % |
|
MONO％ | 8.07 ％ |
|
RBC | 4.57 ×10^12 /L |
|
HGB | 107 g/L |
|
PLT | 285 ×10^9 /L |
|
Researcher signature | 刘义彬 |
|
Date | 2024-2-26 yyyy-mm-dd |
|
Acidity and allkalinity | Acidity
|
|
pH value | 7 |
|
Urine protein | Negative
|
|
Urine red cell | Negative
|
|
Urine WBC | Negative
|
|
Urine glucos | Negative
|
|
Urine Bilirubin | Negative
|
|
Urine HCG | |
|
KET | Negative
|
|
SG | 1.031 |
|
UBG | Negative
|
|
NIT | Negative
|
|
Date of test | 2024-2-26 yyyy-mm-dd |
|
Date of test | 2024-2-26 yyyy-mm-dd |
|
K | 4.59 mmol/L |
|
Na | 143.8 mmol/L |
|
Cl | 105.6 mmol/L |
|
Ca | 2.23 mmol/L |
|
P | 1.40 mmol/L |
|
Date of examination | 2024-2-26 yyyy-mm-dd |
|
Prothrombin time | 10.9 秒 |
|
Thrombin time (TT) | 16.6 秒 |
|
Activated partial thromboplastin time (APTT) | 33.3 秒 |
|
Fibrinogen (FIB) | 2.29 g/L |
|
ALT | 12.0 IU/L |
|
AST | 15.5 IU/L |
|
GGT | 12.0 U/L |
|
Serum bilirubin | 15.5 μmol/L |
|
Indirect bilirubin | 11.50 umol/L |
|
Direct bilirubin | 4.0 umol/L |
|
Serum albumin | 40.7 g/L |
|
Serum globulin | 25.8 g/L |
|
Serum total protein | 66.5 g/L |
|
Date of test | 2024-2-26 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-2-26 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-2-26 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-2-26 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-2-26 yyyy-mm-dd |
|
SCr | 67.0 μmol/L |
|
Blood urea | 7.5 mmol/L |
|
Blood uric acid | 331.0 μmol/L |
|
Date of test | 2024--2-26 yyyy-mm-dd |
|
D-dimer value | 0.10 ug/mL |
|
Date of test | 2024-2-26 |
|
Urine pregnancy test | Not tested
|
|
Blood HCG concentration | -- mIU/mL |
|
Date of test | 2024-2-26 yyyy-mm-dd |
|
Size of the ulcer | 45.4*4.3*482 cm*cm |
|
Uterine echo distribution | Even
|
|
Endometrial thickness | 4.2 mm |
|
Left ovary size | 3.2*2.1 cm ×cm |
|
Shape of Left ovary | Ovarian cyst
|
|
Size of the Ovarian cyst | 1.1 1.02 2.1 3个 |
|
Right ovary size | 6.1*4.2 cm ×cm |
|
Shape of right ovary | Ovarian cyst
|
|
Size of Ovarian cyst | 5.2cm |
|
Description of other abnormal findings | -- |
|
Diagnosis of the Ultrasound B | 双卵巢巧囊 |
|
Doctor signature | 刘义彬 |
|
Date of examination | 2024-2-27 yyyy-mm-dd |
|
Pain Visual Analogue Score | Occasionally very slight pain
|
|
PH | 未查 |
|
PCO2 | mmHg |
|
P02 | mmHg |
|
SO2 | ％ |
|
HCO3 | 未查 mmol/l |
|
SBE | mmol/l |
|
LAC | mmol/L |
|
Date of examination | 未查 (yyyy-mm-dd) |
双侧附件 |
|
左侧2Cm 右侧5cm cm |
|
-- ° |
|
| / | |
刘义彬 |
|
2024-3-1 |
|
D-dimer value | 0.17 ug/mL |
|
Date of test | 2024-3-2 |
|
Body temperature | 37 ℃ |
|
Systolic pressure (SP) | 116 mmHg |
|
Diastolic pressure (DP) | 93 mmHg |
|
Heart Rate, HR | 75 次/分 |
|
Pulse | 75 次/秒 |
|
WBC | 8.1 ×109 /L |
|
NEUT% | 75.99 % |
|
LY% | 16.26 % |
|
MONO％ | 7.23 ％ |
|
RBC | 4.30 ×10^12 /L |
|
HGB | 106 g/L |
|
PLT | 249 ×10^9 /L |
|
Date | 2024-3-2 yyyy-mm-dd |
| / | |
|
Pain Visual Analogue Score | Occasionally very slight pain
|
|
sample collection | Collected
|
|
Volume | 2 ml |
|
Time of collection | 2024-2-27 yyyy-mm-dd-hh-min. |
|
Label Number of the sample | 2567927 |
|
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 |