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CABACS Case Report Form [Day 7 post-Op]

1 Formulär  
Day 7 post surgery
Beskrivning

Day 7 post surgery

Date of visit
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Patient ID
Beskrivning

Patient Study ID

Datatyp

text

Alias
UMLS CUI [1]
C2348585
ECG
Beskrivning

ECG

Date ECG was performed
Beskrivning

ECG Date

Datatyp

date

Alias
UMLS CUI [1,1]
C0013798
UMLS CUI [1,2]
C0011008
Any pathologic findings in ECG?
Beskrivning

ECG findings

Datatyp

boolean

Alias
UMLS CUI [1]
C0438154
Please specify any pathologic ECG findings
Beskrivning

ECG findings

Datatyp

text

Alias
UMLS CUI [1]
C0438154
Screening: Outcome events
Beskrivning

Screening: Outcome events

Did the patient experience any (transient) visual impairment (since surgery)?
Beskrivning

Visual impairment

Datatyp

boolean

Alias
UMLS CUI [1]
C3665347
Did the patient experience paresthesia or weakness on one side of the body (since surgery)?
Beskrivning

Paresthesia or hemiplegia

Datatyp

boolean

Alias
UMLS CUI [1]
C0030554
UMLS CUI [2]
C0018991
Did the patient experience speech disorder (since surgery)?
Beskrivning

Speech disorder

Datatyp

boolean

Alias
UMLS CUI [1]
C0037822
Did the patient experience any new signs or symptoms (since surgery)?
Beskrivning

New signs or symptoms

Datatyp

boolean

Alias
UMLS CUI [1]
C0037088
Is at least one of the following adverse events present: cerebrovascular stroke, myocardial infaction,technical failure, death? If "yes" please fill in Adverse event form and send to study coordinator within 7 days.
Beskrivning

If you suspect cerebrovascular stroke, please initiate cerebral imaging

Datatyp

boolean

Alias
UMLS CUI [1]
C0877248
Complications
Beskrivning

Complications

Deep wound infection
Beskrivning

Wound infection

Datatyp

boolean

Alias
UMLS CUI [1]
C0043241
Sepsis
Beskrivning

Sepsis

Datatyp

boolean

Alias
UMLS CUI [1]
C0243026
Deep vein thrombosis
Beskrivning

Venous thrombosis

Datatyp

boolean

Alias
UMLS CUI [1]
C0040053
Pulmonary Embolism
Beskrivning

Pulmonary Embolism

Datatyp

boolean

Alias
UMLS CUI [1]
C0034065
Pneumonia
Beskrivning

Pneumonia

Datatyp

boolean

Alias
UMLS CUI [1]
C0032285
Injury of cervical nerves
Beskrivning

Injury of cervical nerves

Datatyp

boolean

Alias
UMLS CUI [1,1]
C1284720
UMLS CUI [1,2]
C0161479
Severe hemodynamic instability longer than 24h
Beskrivning

Hemodynamic instability

Datatyp

boolean

Alias
UMLS CUI [1]
C0948268
Carotid dilatation
Beskrivning

Carotid dilatation

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0012359
UMLS CUI [1,2]
C0007272
Carotid bleeding requiring revision
Beskrivning

Hemorrhage

Datatyp

boolean

Alias
UMLS CUI [1]
C0019080
Deterioration of comorbidity (possibly) because of surgical procedure
Beskrivning

Deterioration of comorbidity

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0563273
UMLS CUI [1,2]
C0009488
Deterioration of comorbidity:If "yes" please specify
Beskrivning

Deterioration of comorbidity

Datatyp

text

Alias
UMLS CUI [1,1]
C0563273
UMLS CUI [1,2]
C0009488
Other relevant complications
Beskrivning

Other relevant complications

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0009566
UMLS CUI [1,2]
C0205394
Other relevant complications:Please specify
Beskrivning

Other relevant complications

Datatyp

text

Alias
UMLS CUI [1,1]
C0009566
UMLS CUI [1,2]
C0205394
Serious adverse events
Beskrivning

Serious adverse events

Re-CEA/unplanned CEA
Beskrivning

Please fill in SAE form and send to study coordinator within 7 days via fax

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0014099
UMLS CUI [1,2]
C1527075
Resuscitation
Beskrivning

Please fill in SAE form and send to study coordinator within 7 days via fax

Datatyp

boolean

Alias
UMLS CUI [1]
C0007203
Did any serious adverse events occur?
Beskrivning

Please fill in SAE form and send to study coordinator within 7 days via fax

Datatyp

boolean

Alias
UMLS CUI [1]
C1519255
Date of completion of this form
Beskrivning

Date of completion

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Signature by investigator
Beskrivning

Signature

Datatyp

text

Alias
UMLS CUI [1]
C1519316
Name of Investigator
Beskrivning

Name of Investigator

Datatyp

text

Alias
UMLS CUI [1]
C0008961
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Similar models

CABACS Case Report Form [Day 7 post-Op]

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Day 7 post surgery
Date
Item
Date of visit
date
C0011008 (UMLS CUI [1])
Patient Study ID
Item
Patient ID
text
C2348585 (UMLS CUI [1])
Item Group
ECG
ECG Date
Item
Date ECG was performed
date
C0013798 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
ECG findings
Item
Any pathologic findings in ECG?
boolean
C0438154 (UMLS CUI [1])
ECG findings
Item
Please specify any pathologic ECG findings
text
C0438154 (UMLS CUI [1])
Item Group
Screening: Outcome events
Visual impairment
Item
Did the patient experience any (transient) visual impairment (since surgery)?
boolean
C3665347 (UMLS CUI [1])
Paresthesia or hemiplegia
Item
Did the patient experience paresthesia or weakness on one side of the body (since surgery)?
boolean
C0030554 (UMLS CUI [1])
C0018991 (UMLS CUI [2])
Speech disorder
Item
Did the patient experience speech disorder (since surgery)?
boolean
C0037822 (UMLS CUI [1])
New signs or symptoms
Item
Did the patient experience any new signs or symptoms (since surgery)?
boolean
C0037088 (UMLS CUI [1])
Adverse event
Item
Is at least one of the following adverse events present: cerebrovascular stroke, myocardial infaction,technical failure, death? If "yes" please fill in Adverse event form and send to study coordinator within 7 days.
boolean
C0877248 (UMLS CUI [1])
Item Group
Complications
Wound infection
Item
Deep wound infection
boolean
C0043241 (UMLS CUI [1])
Sepsis
Item
Sepsis
boolean
C0243026 (UMLS CUI [1])
Venous thrombosis
Item
Deep vein thrombosis
boolean
C0040053 (UMLS CUI [1])
Pulmonary Embolism
Item
Pulmonary Embolism
boolean
C0034065 (UMLS CUI [1])
Pneumonia
Item
Pneumonia
boolean
C0032285 (UMLS CUI [1])
Injury of cervical nerves
Item
Injury of cervical nerves
boolean
C1284720 (UMLS CUI [1,1])
C0161479 (UMLS CUI [1,2])
Hemodynamic instability
Item
Severe hemodynamic instability longer than 24h
boolean
C0948268 (UMLS CUI [1])
Carotid dilatation
Item
Carotid dilatation
boolean
C0012359 (UMLS CUI [1,1])
C0007272 (UMLS CUI [1,2])
Hemorrhage
Item
Carotid bleeding requiring revision
boolean
C0019080 (UMLS CUI [1])
Deterioration of comorbidity
Item
Deterioration of comorbidity (possibly) because of surgical procedure
boolean
C0563273 (UMLS CUI [1,1])
C0009488 (UMLS CUI [1,2])
Deterioration of comorbidity
Item
Deterioration of comorbidity:If "yes" please specify
text
C0563273 (UMLS CUI [1,1])
C0009488 (UMLS CUI [1,2])
Other relevant complications
Item
Other relevant complications
boolean
C0009566 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Other relevant complications
Item
Other relevant complications:Please specify
text
C0009566 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Serious adverse events
Re-CEA
Item
Re-CEA/unplanned CEA
boolean
C0014099 (UMLS CUI [1,1])
C1527075 (UMLS CUI [1,2])
Resuscitation
Item
Resuscitation
boolean
C0007203 (UMLS CUI [1])
Serious adverse events
Item
Did any serious adverse events occur?
boolean
C1519255 (UMLS CUI [1])
Date of completion
Item
Date of completion of this form
date
C0011008 (UMLS CUI [1])
Signature
Item
Signature by investigator
text
C1519316 (UMLS CUI [1])
Name of Investigator
Item
Name of Investigator
text
C0008961 (UMLS CUI [1])
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