Date of admission
Item
1. Date of admission (dd mon yy)
date
C1302393 (UMLS CUI [1])
Date of Discharge
Item
2. Date of discharge (dd mon yy)
date
C2361123 (UMLS CUI [1])
intensive care unit
Item
3. Did the patient spend any days at the Intensive Care Unit (ICU) during the hospitalization?
boolean
C0021708 (UMLS CUI [1,1])
C0030673 (UMLS CUI [1,2])
Number of days
Item
If yes, number of days.
float
C0809949 (UMLS CUI [1,1])
C0021708 (UMLS CUI [1,2])
C0439228 (UMLS CUI [1,3])
C0750480 (UMLS CUI [1,4])
Reason for admission
Item
4. Was the reason for admission an outcome event?
boolean
C0392360 (UMLS CUI [1,1])
C0809949 (UMLS CUI [1,2])
Item
If yes, please indicate which outcome event and complete the respective outcome event form. NOTE: there is no outcome event form for TTP or neutropenia
integer
C1547647 (UMLS CUI [1,1])
C0441471 (UMLS CUI [1,2])
Code List
If yes, please indicate which outcome event and complete the respective outcome event form. NOTE: there is no outcome event form for TTP or neutropenia
CL Item
Myocardial infarction (2)
CL Item
Congestive Heart Failure (3)
CL Item
Hemorrhagic event (5)
CL Item
Severe Neutropenia (8)
Item
If NO, please indicate reason for admission and complete the Serious Adverse event form.
integer
C0681841 (UMLS CUI [1])
Code List
If NO, please indicate reason for admission and complete the Serious Adverse event form.
CL Item
Unstable Angina (3)
CL Item
Genito-urinary (4)
CL Item
Gastrointestinal (8)
Specification
Item
Specify "Other"
text
C2348235 (UMLS CUI [1])
Outcome events during hospitalization
Item
5. Did the patients experience outcome events during hospitalization? If yes, please complete respective Outcome Event Forms.
boolean
C1705586 (UMLS CUI [1,1])
C0019993 (UMLS CUI [1,2])
Performed Procedures
Item
6. Were any of the following procedures performed?
boolean
C0087111 (UMLS CUI [1])
Item
If yes, please indicate which:
integer
C3146298 (UMLS CUI [1])
Code List
If yes, please indicate which:
CL Item
Coronary angiography (1)
CL Item
Temporary Pacemaker (3)
CL Item
Carotid stenting (4)
CL Item
Carotid endarterectomy (6)
CL Item
Permanent Pacemaker insertion (7)
CL Item
Other procedures (8)
Specification
Item
Specify "Other"
text
C2348235 (UMLS CUI [1])
Item
7. What was the patients discharge destination?
integer
C0079220 (UMLS CUI [1,1])
C0586514 (UMLS CUI [1,2])
Code List
7. What was the patients discharge destination?
CL Item
Assisted living (2)
CL Item
Not applicable (3)
CL Item
Rehabilitation Centre (4)
CL Item
Other destination (6)
Specification
Item
Specify "Other destination"
text
C0079220 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Invenstigator´s Declaration
Item
8. Invenstigator´s Declaration 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
C0011008 (UMLS CUI [1,1])
C1519316 (UMLS CUI [1,2])