Patient on study medication
Item
1. Was the patient on study medication within the 7 days prior to event?
boolean
C0013227 (UMLS CUI [1])
Item
If NO, which medication was the patient was not taking (please indicate all that apply):
integer
C0030705 (UMLS CUI [1,1])
C0457432 (UMLS CUI [1,2])
Code List
If NO, which medication was the patient was not taking (please indicate all that apply):
CL Item
Blister card C (3)
CL Item
Blister card D (4)
Pulmonary embolism
Item
2. Pulmonary embolism
boolean
C0034065 (UMLS CUI [1])
If Yes
Item
If Yes please complete the date of event (dd mon yy)
date
C0011008 (UMLS CUI [1])
ancillary examination
Item
Please indicate the supporting ancillary examinations:
text
C0582103 (UMLS CUI [1])
Angiography
Item
Angiography
boolean
C0002978 (UMLS CUI [1])
V/Q Scan
Item
V/Q Scan
boolean
C0849974 (UMLS CUI [1])
Deep vein thrombosis
Item
3. Deep vein thrombosis
boolean
C0149871 (UMLS CUI [1])
If Yes
Item
If Yes please complete the date of event (dd mon yy)
date
C0011008 (UMLS CUI [1])
ancillary examination
Item
Please indicate the supporting ancillary examinations:
text
C0582103 (UMLS CUI [1])
Doppler
Item
Doppler
boolean
C0242845 (UMLS CUI [1])
Angiography
Item
Angiography
boolean
C0002978 (UMLS CUI [1])
Scintigraphy
Item
Scintigraphy
boolean
C0034606 (UMLS CUI [1])
Retinal Vascular accidents
Item
4. Retinal Vascular accidents (not confirmed as retinal arterial occlusion)
boolean
C0035309 (UMLS CUI [1])
If Yes
Item
If Yes please complete the date of event (dd mon yy)
date
C0011008 (UMLS CUI [1])
Peripheral Arterial Occlusion
Item
5. Peripheral Arterial Occlusion
boolean
C1306889 (UMLS CUI [1])
If Yes
Item
If Yes please complete the date of event (dd mon yy)
date
C0011008 (UMLS CUI [1])
ancillary examination
Item
Please indicate the supporting ancillary examinations:
text
C0582103 (UMLS CUI [1])
Doppler
Item
Doppler
boolean
C0242845 (UMLS CUI [1])
Angiography
Item
Angiography
boolean
C0002978 (UMLS CUI [1])
claudication
Item
Were clinical symptoms of claudication observed?
boolean
C1456822 (UMLS CUI [1])
gangrene
Item
Was gangrene observed?
boolean
C0017086 (UMLS CUI [1])
Transient Ischemic Attack
Item
6. Transient Ischemic Attack
boolean
C0007787 (UMLS CUI [1])
duration of event
Item
If Yes please complete the duration of event
time
C0449238 (UMLS CUI [1])
Hospitalization
Item
7. Did the lead to hospitalization? If Yes please complete the Hospitalization Report Form.
boolean
C0019993 (UMLS CUI [1])
Fatal Event
Item
8. Was the event fatal (death within 28 days)? If yes please complete Death Report Form.
boolean
Invenstigator´s Declaration
Item
9. By signing and dating this page, I declare that I have reviewed for accuracy all case report form pages for this patient; the information contained on these pages accurately reflects the medical record including the results of tests and evaluations performed in the dates specified.
text
Investigator´s signature
Item
Investigator´s signature
text
C2346576 (UMLS CUI [1])
Date of Signature
Item
Date of Signature
date
C0807937 (UMLS CUI [1])
