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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 | 2024-5-22 |
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Date of birth | 2005-10-22 yyyy-mm-dd |
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Age | 18 Years |
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Education background | Middle school
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Occupation | Other
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Other (Description) | 学生 |
72 小时 |
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无 |
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Number of pregnancy | 0 次 |
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Number of delivery | 0 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 | 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 | 2024-4-20 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) |
无 |
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-- 年/月/日（yyyy-mm-dd） |
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Namy of the drug to be allergied | 无 |
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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 | 85 kg |
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Hight | 172 mm |
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Systolic pressure (SP) | 106 mmHg |
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Diastolic pressure | 87 mmHg |
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Temperature | 36.8 degree Celsius |
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Pulse rate | 80 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 | 2024-5-13 yyyy-mm-dd |
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WBC | 5.60 ×109 /L |
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NEUT% | 52.42 % |
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LY% | 33.68 % |
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MONO％ | 10.88 ％ |
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RBC | 4.20 ×10^12 /L |
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HGB | 120 g/L |
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PLT | 187 ×10^9 /L |
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Researcher signature | 刘义彬 |
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Date | 2024-5-13 yyyy-mm-dd |
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Acidity and allkalinity | |
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pH value | 未查 |
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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 | 未查 |
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UBG | |
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NIT | |
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Date of test | -- yyyy-mm-dd |
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Date of test | 2024-5-13 yyyy-mm-dd |
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K | 4.08 mmol/L |
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Na | 142.3 mmol/L |
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Cl | 105.2 mmol/L |
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Ca | 2.31 mmol/L |
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P | 1.30 mmol/L |
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Date of examination | 2024-5-113 yyyy-mm-dd |
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Prothrombin time | 10.2 秒 |
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Thrombin time (TT) | 13.5 秒 |
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Activated partial thromboplastin time (APTT) | 32.5 秒 |
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Fibrinogen (FIB) | 3.30 g/L |
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ALT | 11.6 IU/L |
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AST | 19.9 IU/L |
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GGT | 7.9 U/L |
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Serum bilirubin | 8.7 μmol/L |
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Indirect bilirubin | 6.5 umol/L |
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Direct bilirubin | 2.2 umol/L |
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Serum albumin | 41.8 g/L |
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Serum globulin | 21.9 g/L |
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Serum total protein | 63.7 g/L |
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Date of test | 2024-5-13 yyyy-mm-dd |
Negative
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Date of test | 2024-5-13 yyyy-mm-dd |
Negative
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Date of test | 2024-5-13 yyyy-mm-dd |
Negative
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Date of test | 2024-5-13 yyyy-mm-dd |
Negative
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Date of test | 2024-5-13 yyyy-mm-dd |
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SCr | 62.0 μmol/L |
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Blood urea | 3.2 mmol/L |
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Blood uric acid | 235 μmol/L |
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Date of test | 2024-5-13 yyyy-mm-dd |
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D-dimer value | 0.06 ug/mL |
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Date of test | 2024-5-13 |
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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 | 5.1*4.2*3.5 cm*cm |
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Uterine echo distribution | Even
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Endometrial thickness | 8 mm |
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Left ovary size | 2.2*1.3 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 | 8.2*6.2*8.2 cm ×cm |
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Shape of right ovary | Ovarian cyst
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Size of Ovarian cyst | 8cm |
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Description of other abnormal findings |
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Diagnosis of the Ultrasound B | 黄体破裂 右侧输卵管系膜囊肿 |
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Doctor signature | 刘义彬 |
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Date of examination | 2024-5-13 yyyy-mm-dd |
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Pain Visual Analogue Score | Mild pain
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PH | 未查 |
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PCO2 | mmHg |
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P02 | 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 | mmol/L |
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Date of examination | -- (yyyy-mm-dd) |
右卵巢 |
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8cm cm |
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无 ° |
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刘义彬 |
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2024-5-13 |
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D-dimer value | 0.15 ug/mL |
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Date of test | 2024-5-15 |
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Body temperature | 36.4 ℃ |
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Systolic pressure (SP) | 未查 mmHg |
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Diastolic pressure (DP) | 未查 mmHg |
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Heart Rate, HR | 80 次/分 |
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Pulse | 80 次/秒 |
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WBC | 5.8 ×109 /L |
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NEUT% | 62.49 % |
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LY% | 26.74 % |
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MONO％ | 9.32 ％ |
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RBC | 4.16 ×10^12 /L |
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HGB | 118 g/L |
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PLT | 164 ×10^9 /L |
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Date | 2024-5-15 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 | 2 ml |
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Time of collection | 2024-5-13 2024-5-15 yyyy-mm-dd-hh-min. |
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Label Number of the sample | 2595171 |
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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 |