1 Month Followup - Pedimacs

Transcription

1 version date: 03/27/ Month Followup - Pedimacs Followup Status (1 Month Followup (+/- 7 days)) Select one of the following Inpatient Outpatient Other Facility Unable to obtain follow-up information Follow-up date Facility Type Nursing Home/Assisted Care Hospice Another hospital Rehabilitation Facility State reason why you are unable to obtain follow-up information Patient didn't come to clinic t able to contact patient t addressed by site Was patient intubated? Was patient on dialysis? Pump Change Pump Exchange If yes, please select one of the following: Please select appropriate reason: Intracorporeal device Para- or Extra- corporeal device Upsizing device because of patient growth status All other reasons would categorize the pump change as a Device Malfunction Thrombus NOT associated with hemolysis Change in hemodynamics Clinical status Device parameters Was there a Console Change? 1 of 13

2 1 Month Followup - Status version date: 03/27/2018 Date of console change ST= Original Console Name New Console Name Medical Condition NYHA Class Class I: limitation of physical activity; physical activity does not cause fatigue, palpitation or shortness of breath. Class II: Slight limitation of physical activity; comfortable at rest, but ordinary physical activity results in fatigue, palpitations or shortness of breath. Class III: Marked limitation of physical activity; comfortable at rest, but less than ordinary activity causes fatigue, palpitation or shortness of breath. Class IV: Unable to carry on minimal physical activity without discomfort; symptoms may be present at rest. Ross Classification of Congestive Heart Failure Ross Class I: limitations or symptoms. Ross Class II: growth failure. Ross Class III: Growth failure. Ross Class IV: Symptomatic at rest. t applicable: >= 2 years of age Choose all indicated symptoms that apply. Choose all indicated symptoms that apply. Choose all indicated symptoms that apply. Mild tachypnea with feeds in infant Mild diaphoresis with feeds in infant Dyspnea on exercise in older children Marked tachypnea with exertion or with feeding Marked diaphoresis with exertion or with feeding Tachypnea Retractions Grunting Diaphoresis Functional Capacity Sedated Paralyzed Intubated 2 of 13

3 1 Month Followup - Status version date: 03/27/2018 Ambulating Primary Nutrition Orally Per feeding tube TPN t Applicable Excursions Has the patient had any nonmedically required excursions off the unit? If yes, where (please select all that apply) t Applicable Playroom Cafeteria Walk outside Sitting room General rehab ne ZONES Hemolysis Zone Please enter the peak Plasma-free hemoglobin (PFH) since the last visit: ST= t Done What is your hospital s upper limit of the normal range of peak PFH? ST= t Done Please enter the peak serum lactate dehydrogenase (LDH) since the last visit: ST= t Done What is your hospital s upper limit of the normal range of LDH? ST= t Done Enter the Maximum and Minimum HCT or HGB since the last visit. Min. HCT: ST= t Done 3 of 13

4 1 Month Followup - Status version date: 03/27/2018 Max. HCT: ST= t Done Min. HGB: ST= t Done Max. HGB: ST= t Done Highest Total Bilirubin since the last visit: ST= t Done Has the following been present at any time since the last visit? Physical Findings (select all that apply): Hemoglobinuria (Tea-Colored Urine)? Pump malfunction and/or abnormal pump parameters? Right Heart Failure Zone Clinical Findings Since the last visit. CVP or RAP > 16 mmhg? t Done Dilated Vena Cava with absence of Inspiratory Variation by Echo? t Done Clinical findings of elevated jugular venous distension at least half way up the neck in an upright patient? Peripheral Edema? Ascites? 4 of 13

5 1 Month Followup - Status version date: 03/27/2018 Has the patient been on Inotropes since the last visit? If yes, select all that apply: Dopamine Dobutamine Milrinone Isoproterenol Epinephrine repinephrine Levosimendan Vasopressin Nitroprusside Fenoldopam Prostacyclin Nesiritide? Has the patient had a RVAD implant since the last visit? Has the patient experienced a Neurological Event since time of implant? If yes, please enter the Modified Rankin Scale. Modified Rankin Scale 0 symptoms at all 1 - Significant disability: despite symptoms: able to carry out all usual duties and activities 2 - Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance 3 - Moderate disability: requiring some help, but able to walk without assistance. 4 - Moderately severe disability: unable to walk without assistance, and unable to attend to own bodily needs without assistance. 5 - Severe disability: bedridden, incontinent and requiring constant nursing care and attention. 6 - Dead ST= t Documented t Done 5 of 13

6 version date: 03/27/ Month Followup - Pedimacs Hemodynamics General Hemodynamics Systolic blood pressure ST= t done mmhg Diastolic blood pressure ST= t done mmhg Mean Arterial Blood Pressure (MAP) mmhg ST= t done ECG rhythm Sinus Atrial fibrillation Atrial Flutter Paced: Atrial pacing Paced: Ventricular pacing Paced: Atrial and ventricular pacing t done Other, specify Height ST= t done in cm Weight ST= t done lbs kg Invasive Hemodynamics Date of Measurement ST= t Done Pulmonary artery systolic pressure ST= t Done mmhg 6 of 13

7 1 Month Followup - Hemodynamics version date: 03/27/2018 Pulmonary artery diastolic pressure ST= t Done mmhg Mean RA Pressure ST= t Done mmhg PVR wood units ST= t Done Mean Pulmonary artery wedge pressure ST= t Done mmhg Central venous pressure (CVP) mmhg ST= t Done Cardiac Index ST= t Done L/min/M 2 (by Swan) Was Cardiac Index Measured by Fick or Thermodilution? Choose Method Fick Thermodilution 7 of 13

8 version date: 03/27/ Month Followup - Pedimacs Medications Was the patient sent home with an IV? ACE inhibitors Aldosterone antagonist Amiodarone Angiotensin receptor blocker drug Antiplatelet therapy drug Select drug(s) Aspirin Dextran Dipyridamole Clopidogrel Ticlopidine Other, specify Thrombolytic Beta-blockers Calcium channel blockers Digoxin 8 of 13

9 1 Month Followup - Medications version date: 03/27/2018 Hydralazine Loop diuretics If yes, enter dosage: mg/day ST= Type of Loop Diuretic: Furosemide Torsemide Bumetanide Other Low molecular weight heparin (Lovenox, Fragmin, Innohep) Nitric oxide Sildenafil/ Bosentan UFH: Unfractionated Heparin Warfarin (coumadin) Arixtra (fondaparinux) Did patient receive new IV or oral medication to treat hypertension? Transfusion Was there a Tranfusion? If yes, enter number of PRBC (Total number of cc's received) ST= 9 of 13

10 version date: 03/27/ Month Followup - Pedimacs Laboratory Sodium meq/l ST= t done mmol/l Potassium meq/l ST= t done mmol/l Blood urea nitrogen mg/dl ST= t done mmol/l Creatinine mg/dl ST= t done umol/l SGPT/ALT (alanine aminotransferase/alt) ST= t done u/l SGOT/AST (aspartate aminotransferase/ast) ST= t done u/l LDH units/l, U/L, ukat/l ST= t done Total bilirubin mg/dl ST= t done umol/l Bilirubin direct mg/dl ST= t Done umol/l 10 of 13

11 1 Month Followup - Laboratory version date: 03/27/2018 Bilirubin indirect mg/dl ST= t Done umol/l Albumin g/dl ST= t done g/l Pre-albumin mg/dl ST= t done mg/l Total Cholesterol ST= < 50 mg/dl t done mg/dl mmol/l Brain natriuretic peptide BNP ST= > 7500 pg/ml t done pg/ml ng/l NT pro brain natriuretic peptide Pro- BNP ST= t done pg/ml ng/l White blood cell count ST= t done x10 3 /ul x10 9 /ul Reticulocyte count % ST= t Done Hemoglobin g/dl ST= t done g/l mmol/l 11 of 13

12 1 Month Followup - Laboratory version date: 03/27/2018 Hemoglobin A1C % Estimated Average Glucose (eag): ST= t Done mmol/mol mg/dl mmol/l Platelets ST= t done x10 3 /ul x10 9 /ul INR international units ST= t done Plasma-free hemoglobin mg/dl ST= t Done g/l Positive antiheparin/platelet antibody (HIT) If, are they on direct thrombin inhibitors If, Enter Drugs: Aspirin Dipyridamole Plavix Heparin Coumadin Direct thrombin inhibitors (ex: arg, lip, val ) Was a TEG done? ThrombElastoGraph Hemostasis System (TEG) profile, MA k ThrombElastoGraph Hemostasis System (TEG) profile, R k ST= t Done ST= t Done max amplitude in kaolin reaction time in kaolin 12 of 13

13 1 Month Followup - Laboratory version date: 03/27/2018 ThrombElastoGraph HemostasisSystem (TEG) profile, R h ST= t Done reaction time w/heparinase CRP or hs-crp ST= t done mg/dl Lupus Anticoagulant Positive Negative 13 of 13