Pediatric Bleeding Questionnaire (PBQ)

Transcription

1 Date Patient Number Patient Name Gender Male Female Age DOB (dd/mm/yy) Ethnic Background of: Father Mother Presenting complaint of bleeding or bruising today? Ever been diagnosed with a bleeding disorder? Diagnosis: Total # of 1 st degree family members # of 1 st degree family members studied # of diagnosed 1 st degree family members tes: ABO Blood Group A B AB O Rh - Rh + Present questionnaire completed by Father Mother Patient Menarche N/A Age of menarche: Are you currently taking oral contraceptive pills? Brand Name: Specify any herbals and/or medications that you have taken in the past 30 days: Name Dose Route Frequency Duration Past Medical History: August 16, 2010 (Revised for clinical use) Page 1 of 13

2 Bleeding symptoms Pediatric Bleeding Questionnaire (PBQ) Epistaxis If, Trivial Significant AVERAGE PRESENTATION Significant: Any nosebleed lasting for longer than 10 minutes OR requiring medical attention OR occurring frequently (greater than 5 times per year). Age of maximum severity 0-4 years 4-8 years 8-12 years years years Number episodes/year < > 12 Duration of average single episode < 1 minute 1-10 minutes > 10 minutes Spontaneous? Both nostrils? After drug ingestion (e.g. aspirin) Seasonal correlation Cessation Specify: spontaneous after compression by medical intervention Packing Cauterization tes REPORT TREATMENT OF THE MOST SEVERE EPISODE August 16, 2010 (Revised for clinical use) Page 2 of 13

3 Cutaneous symptoms If, Trivial Significant Type Location of lesions (if any) Size of average AVERAGE PRESENTATION Petechiae Bruises Hematomas Exposed sites Unexposed sites Both < 1 cm 1 5 cm > 5 cm Minimal or no trauma REPORT TREATMENT OF THE MOST SEVERE EPISODE Significant: Spontaneous bruises larger than 1 cm in diameter (the size of a pea) OR considered disproportionate to trauma by the investigator. All petechiae are considered to be significant. tes Bleeding from minor wounds If, Trivial Significant AVERAGE PRESENTATION Significant: Prolonged bleeding, lasting longer than 5 minutes, caused by a superficial cut. Number episodes/year < > 12 Duration of average single episode < 5 mins. > 5 mins. Consultation or Steri-strips Surgical hemostasis tes REPORT TREATMENT OF THE MOST SEVERE EPISODE August 16, 2010 (Revised for clinical use) Page 3 of 13

4 Oral cavity bleeding If, Trivial Significant Type of bleeding Surgical hemostasis tes Significant: Either spontaneous gum bleeding lasting for longer than a minute OR bites to lips/cheeks/tongue lasting longer than 5 minutes OR bleeding at tooth eruption requiring assistance by a physician. AVERAGE PRESENTATION Tooth eruption/loss Gums, spontaneous Gums, after brushing Prolonged bleeding after bites to lip & tongue Hemorrhagic bullae REPORT TREATMENT OF THE MOST SEVERE EPISODE Tooth extraction If, Trivial Significant Significant: Any bleeding occurring after leaving the dentist s office or prolonged bleeding causing a delay in discharge from the dentist s office. Total # of teeth extracted # of teeth extracted followed by bleeding MOST SEVERE OCCURRENCE Age at extraction Type of extraction Deciduous Permanent ne Prophylaxis before extraction? Bleeding after extraction? Actions taken to control bleeding tes ne Resuturing Packing August 16, 2010 (Revised for clinical use) Page 4 of 13

5 Gastrointestinal bleeding (N.B.: All GI bleeding is considered to be significant.) AVERAGE PRESENTATION # of episodes Type of bleeding Presence of associated GI disease Surgical hemostasis tes Hematemesis Melena Hematochezia Gastritis/ulcer Colitis Mallory-Weiss tear Vascular malformations Other REPORT TREATMENT OF THE MOST SEVERE EPISODE August 16, 2010 (Revised for clinical use) Page 5 of 13

6 Surgery If, Trivial Significant Significant: Any bleeding stated as abnormally prolonged by the surgeon OR causing a delay in discharge OR requiring some supportive treatment. Total # of surgeries Specify # of surgeries followed by bleeding MOST SEVERE OCCURRENCE Age at surgery Type of surgery Specify Prophylaxis before surgery? ne Bleeding after surgery? Actions taken to control bleeding ne Resuturing/surgical tes August 16, 2010 (Revised for clinical use) Page 6 of 13

7 Menorrhagia N/A Duration of average menstruation (days) How often do you change your pads/tampons Duration of heavy (days) on heaviest days hours on average days hours What type of feminine product do you use? (i.e. panty liner, super absorbency tampon etc.) Comments MOST SEVERE PRESENTATION Age of maximum severity 8-12 Pill use Dilatation & curettage Iron therapy Hysterectomy >20 yrs tes August 16, 2010 (Revised for clinical use) Page 7 of 13

8 Post-partum hemorrhage Total # of deliveries N/A If, Trivial Significant # of deliveries followed by bleeding Significant: Any bleeding stated as abnormally prolonged by the obstetrician OR causing a delay in discharge OR requiring some supportive treatment. MOST SEVERE OCCURRENCE Age at delivery Mode of delivery spontaneous assisted c-section ne Prophylaxis before delivery Bleeding after delivery? Actions taken to control bleeding ne Resuturing/surgical Hysterectomy tes August 16, 2010 (Revised for clinical use) Page 8 of 13

9 Muscle hematomas (N.B.: All muscle hematomas are considered to be significant.) Total # MOST SEVERE PRESENTATION Please specify type & location Post-trauma? Prophylaxis? Surgical intervention ne tes August 16, 2010 (Revised for clinical use) Page 9 of 13

10 Hemarthrosis (N.B.: All episodes of hemarthrosis are considered to be significant.) Total # MOST SEVERE PRESENTATION Please specify type & location Post-trauma? Prophylaxis? Surgical intervention ne tes CNS bleeding (N.B.: All episodes of CNS bleeding are considered to be significant.) If yes, type of bleeding Subdural, any intervention Intracerebral, any intervention August 16, 2010 (Revised for clinical use) Page 10 of 13

11 Other bleeding (N.B.: All episodes of any of these bleeding symptoms are considered to be significant.) If yes, type of bleeding Umbilical stump Cephalohematoma Bleeding at circumcision Venipuncture bleeding Male, not circumcised Male, circumcised Female Conjunctival hemorrage Hematuria, macroscopic MOST SEVERE PRESENTATION Please specify type Iron therapy Surgical hemostasis tes August 16, 2010 (Revised for clinical use) Page 11 of 13

12 Other bleeding (continued) Please specify type MOST SEVERE PRESENTATION Iron therapy Surgical hemostasis tes Please specify type MOST SEVERE PRESENTATION Iron therapy Surgical hemostasis tes August 16, 2010 (Revised for clinical use) Page 12 of 13

13 Symptom Score Pediatric Bleeding Questionnaire (PBQ) Epistaxis - or trivial ( 5 per year) >5 per year OR >10 minutes duration Packing, cauterization or antifibrinolytics, replacement therapy or desmopressin Cutaneous - or trivial ( 1cm) >1cm AND no trauma - - Minor wounds - or trivial ( 5 per year) >5 per year OR >5 minutes duration or Steri-strips Surgical hemostasis or antifibrinolytics, replacement therapy or desmopressin Oral cavity - Reported at least once Surgical hemostasis or antifibrinolytics, replacement therapy or desmopressin Gastrointestinal tract - Identified cause Consultation or spontaneous Surgical hemostasis, antifibrinolytics, blood transfusion, replacement therapy or desmopressin - Tooth extraction bleeding in at least 2 extractions ne done or no bleeding in 1 extraction Reported, no consultation Resuturing, repacking or antifibrinolytics, replacement therapy or desmopressin Surgery bleeding in at least 2 surgeries ne done or no bleeding in 1 Reported, no consultation Surgical hemostasis or antifibrinolytics, replacement therapy or desmopressin Menorrhagia - Reported or consultation only or contraceptive pill use D&C or iron therapy, replacement therapy, desmopressin or hysterectomy Post-partum bleeding in at least 2 deliveries deliveries or no bleeding in 1 delivery Reported or consultation only D&C, iron therapy or antifibrinolytics, replacement therapy or desmopressin - Muscle hematoma - Never Post-trauma, no therapy Spontaneous, no therapy Hemarthrosis - Never Post-trauma, no therapy Spontaneous, no therapy Spontaneous or traumatic, requiring replacement therapy or desmopressin Spontaneous or traumatic, requiring replacement therapy or desmopressin Spontaneous or traumatic, requiring surgical intervention or blood transfusion Spontaneous or traumatic, requiring surgical intervention or blood transfusion Central nervous system - Never - - Subdural, any intervention Intracerebral, any intervention Other Post-circumcision Umbilical stump Cephalohematoma Macroscopic hematuria Post-venepuncture Conjunctival hemorrage - Reported Surgical hemostasis, antifibrinolytics or iron therapy, replacement therapy or desmopressin August 16, 2010 (Revised for clinical use) Page 13 of 13