APPENDIX F: CASE REPORT FORM

Transcription

1 APPENDIX F: CASE REPORT FORM

2 Instruction: Complete this form to notify all ACS admissions at your centre to National Cardiovascular Disease Registry. Where check boxes are provided, check ( ) one or more boxes. Where radio buttons are provided, check ( ) one box only. A. Reporting centre: B. Date of Admission : SECTION 1 : DEMOGRAPHICS 1. Patient Name : 3. Identification Card Number : 4. Gender: MyKad / MyKid: Other ID document : Male - - 5a. Date of Birth: 5b. Age on admission: d d m m y y 6. Ethnic : Malay Orang Asli Murut Iban Chinese Kadazan Bajau Other M'sian, specify : Indian Melanau Bidayuh Foreigner, specify country of origin: SECTION 2 : STATUS BEFORE EVENT 1. Smoking Status: NATIONAL CARDIOVASCULAR DISEASE DATABASE (NCVD) NOTIFICATION FORM 3. Premorbid or past medical history : Female 7. Contact Number (1): (2): 2. Status of Aspirin Use: a) Dyslipidaemia t known b) Hypertension t known c) Diabetes t known d) Family history of premature t known cardiovascular disease e) Myocardial infarction history t known f) Documented CAD > 50% stenosis t known g) Chronic Angina (onset more than t known 2 weeks ago) SECTION 3 : ONSET 3. Blood pressure at presentation: a. Systolic: (mmhg) b. Diastolic: 4. Anthropometric : a. Height: (cm) b. Weight: (kg) 2. Local RN (if applicable): (mmhg) Old IC: Specify type (eg.passport, armed force ID): For NCVD Use only: ID: / Centre: Never Former (quit >30 days) Current (any tobacco use within last 30 days) ne Used less than 7 days previously Used more than or equal to 7 days previously h) New onset angina (Less than 2 weeks) t known i) Heart failure t known j) Chronic lung disease t known k) Renal disease t known l) Cerebrovascular disease t known m) Peripheral vascular disease t known n) ne of the above 1a. Date of onset of ACS symptoms: 1b. Time of onset of ACS symptoms: d d m m y y h h m m 2a. Date Patient presented : 2b. Time Patient presented : d d m m y y h h m m 3. Was patient transferred from another centre? SECTION 4 : CLINICAL PRESENTATION & EXAMINATION 1. Number of distinct episodes of angina in past 24 hours: 2. Heart rate at presentation: (beats / min) c. Waist Circumference: d. Hip Circumference: t available t available 5. Kilip classification code : I II III IV t stated / inadequately described SECTION 5 : ELECTROCARDIOGRAPHY (ECG) 2. ECG abnormalities location : (Check one or more boxes) Inferior leads: II, III, avf Anterior leads: V1 to V4 Lateral leads: I, avl, V5 to V6 True posterior: V1 V2 NCVD Version 1.20 (last updated on 31/03/06) NCVD copy Page 1 of 3 (cm) (cm) t available t available t available t available BMI: WHR: Right ventricle: ST elevation in lead V4R ne t stated / inadequately described 1. ECG abnormalities type ST-segment elevation 1mm (0.1 mv) in 2 contiguous limb leads Bundle branch block (BBB) (Check one or more boxes) t available ST-segment elevation 2mm (0.2 mv) in 2 contiguous frontal leads or chest leads ST-segment depression 0.5mm (0.05 mv) in 2 contiguous leads T-wave inversion 1mm (0.1 mv) n-specific ne t stated / inadequately described

3 a. Patient Name : c. Identification Card Number : b. Local RN (if applicable): SECTION 6 : BASELINE INVESTIGATIONS (Values obtained within 48 hours from admission) Absolute values Unit Reference upper limits Check ( ) if not done 1. Peak CK-MB 2. Peak CK 3. Peak Troponin: a. T n T: b. T n I: +ve +ve -ve -ve OR OR Unit/L Unit/L ng/ml or mcg/l ng/ml or mcg/l t done t done t done t done 4. Lipid a. Total cholesterol: t done profile (Fasting): b. HDL-C: t done c. LDL-C: t done d. Triglycerides: t done 5. Fasting Blood Glucose: t done 6. Left Ventricular Ejection Fraction: % t done SECTION 7 : CLINICAL DIAGNOSIS AT ADMISSION 1. Acute coronary syndrome stratum: STEMI NSTEMI UA 2a. TIMI risk score UAP / NSTEMI: : SECTION 8 : FIBRINOLYTIC THERAPY 1. Fibrinolytic therapy status : Fill in (2), (3), (4) only if you check ' at this centre' in (1) above 2b. TIMI risk score STEMI: (Following Section is applicable for STEMI only) at this centre (Please proceed to 2, 3, 4 below) at another centre prior to transfer here t given-proceeded directly to primary angioplasty t given-missed thrombolysis t given-patient refusal t given- Contraindicated 2. Fibrinolytic drug used: Streptokinase Others (t-pa, r-pa, TNK t-pa) 3. Intravenous a. Date: b. Time: fibrinolytic therapy : d d m m y y h h m m 4. Door to needle time: (mins) - (time pt presented to time of intravenous fb ty) SECTION 9 : INVASIVE THERAPEUTIC PROCEDURES 1. Did patient undergo cardiac catheterization on this admission at your centre? 2. Did patient undergo percutaneous coronary intervention on this admission? (If or t Applicable, Please skip 5, 6 & 7b below) - Transferred to another centre a. For STEMI t applicable Primary PCI Rescue PCI Facilitated PCI Routine hospital practice? b. For NSTEMI / UA Routine hospital practice? 3a. Number of diseased vessels: b. Left Main Stem involvement: 4. Culprit artery: 5. First balloon inflation: LAD a. Date: LCx RCA b. Time: LM Bypass Graft (for STEMI - PCI only) d d m m y y h h m m 6. Door to balloon time (mins): (for STEMI - PCI only) - (time pt presented to time of first angio balloon inflation ) 7a(i). TIMI flow classification pre-pci: 0 I II III 7a(ii). Intra-coronary Thrombus present? 7b. TIMI flow classification post-pci: 0 I II III 8. PCI type: Angioplasty 9. Did patient undergo CABG on this admission? NCVD Version 1.20 (last updated on 31/03/06) Stenting a) Direct stenting b) Pre-dilatation done c) Stent type: Drug-eluting d) Stent type: Bare-metal a. Date of CABG: d d m m y y NCVD copy Page 2 of 3

4 a. Patient Name : c. Identification Card Number : SECTION 10 : PHARMACOLOGICAL THERAPY pre admission b. Local RN (if applicable): (used / given during admission) during admission after discharge 1. ASA 2. ADP antagonist 3. GP receptor inhibitor 4. Unfrac Heparin 5. LMWH 6. Beta blocker 7. ACE Inhibitor 8. Angiotensin II receptor blocker 9. Statin 10. Other lipid lowering agent 11. Diuretics 12. Calcium antagonist 13. Oral Hypoglycaemic agent 14. Insulin 15. Anti-arrhythmic agent SECTION 11 : IN-HOSPITAL CLINICAL OUTCOMES 1. Number of overnight stays a. CCU b. ICU / CICU: 2. Outcome: Discharged days days b. Total number of overnight stays: Transferred to another centre b. Name of Centre : Died b. Cause of Death : 3. Final diagnosis at discharge: Q wave MI non-q wave MI Unstable angina Stable angina n-cardiac Cardiovascular n Cardiovascular Other,specify : 4. Bleeding Complication (TIMI Criteria): Major Minor ne t stated / Inadequately described NCVD Version 1.20 (last updated on 31/03/06) NCVD copy Page 3 of 3

5 NATIONAL CARDIOVASCULAR DISEASE DATABASE FOLLOW UP FORM AT 30 DAYS For NCVD Use only: ID: / Centre: Instruction: This form is to be completed at patient follow-up 30 days (+ 2 weeks) after admission. Following may be performed by clinic visit or telephone interview. Where check boxes are provided, check ( ) one or more boxes. Where radio button are provided, check ( ) one box only. A. Name of reporting centre: B. Patient Name : Hj/Hjh/Dato'/Dr. C. Identification MyKad / MyKid: Card Number : Other ID document : - - Old IC: Specify type (eg.passport, armed force ID): D. Date of Follow up tification: 1. Outcome: 1. Alive 2. Died SECTION 1: OUTCOME a. Date of death: b. Cause of Death: Cardiovascular Other,specify : n Cardiovascular 3. Transferred to another centre : 4. Lost to Follow up: a. Date of last follow-up: b. Name of Centre : a. Date of last follow-up: 2. Cardiovascular readmission: 1. ACS b. ACS Stratum: STEMI NSTEMI UA 2. Heart failure 3. Revascularization 4. Stroke b. Type of Revascularization : 1. PCI 2. CABG SECTION 2: CLINICAL HISTORY AND EXAMINATION (OPTIONAL) 1. Angina Status: (CCS classification) ne Class I Class II Class III Class IV 2. Functional capacity: (NYHA classification) ne NYHA I NYHA II NYHA III NYHA IV 3. BP a. Systolic: mmhg b. Diastolic: mmhg 4. Anthropometric: a. Weight: b. Waist circumference: kg 1. Lipid profile: a. Total cholesterol: b. HDL-C: c. LDL-C: d. Triglycerides: SECTION 3: INVESTIGATIONS (OPTIONAL) Values Unit 2. Left Ventricular Ejection Fraction: % 1. ASA 2. ADP antagonist 5. LMWH 7. ACE Inhibitor 3. GP receptor inhibitor 8. Angiotensin II receptor blocker c. Hip circumference: cm SECTION 4: MEDICATIONS (OPTIONAL) 9. Statin 10. Other lipid lowering agent 11. Diuretics 4. Warfarin 12. Calcium antagonist 6. Beta blocker 15. Anti-arrhythmic agent 1. Was patient referred to cardiac rehabilitation? 2. Has patient stopped smoking? 13. Oral Hypoglycaemic agent 14. Insulin SECTION 5: REHABILITATION AND COUNSELLING (OPTIONAL) cm NCVD F/U Version 1.7 (last updated on 07/03/06) Page 1 of 1

6 NATIONAL CARDIOVASCULAR DISEASE DATABASE FOLLOW UP FORM AT 1 YEAR For NCVD Use only: ID: / Centre: Instruction: This form is to be completed at patient follow-up 1 year ± 1 month after admission. Following may be performed by clinic visit or telephone interview. Where check boxes are provided, check ( ) one or more boxes. Where radio button are provided, check ( ) one box only. A. Name of reporting centre: B. Patient Name : Hj/Hjh/Dato'/Dr. C. Identification MyKad / MyKid: Card Number : Other ID document : - - Old IC: Specify type (eg.passport, armed force ID): D. Date of Follow up tification: 1. Outcome: 1. Alive 2. Died SECTION 1: OUTCOME a. Date of death: b. Cause of Death: Cardiovascular Other,specify : n Cardiovascular 3. Transferred to another centre : 4. Lost to Follow up: a. Date of last follow-up: b. Name of Centre : a. Date of last follow-up: 2. Cardiovascular readmission: 1. ACS b. ACS Stratum: STEMI NSTEMI UA 2. Heart failure 3. Revascularization 4. Stroke b. Type of Revascularization : 1. PCI 2. CABG SECTION 2: CLINICAL HISTORY AND EXAMINATION 1. Angina Status: (CCS classification) ne Class I Class II Class III Class IV 2. Functional capacity: (NYHA classification) ne NYHA I NYHA II NYHA III NYHA IV 3. BP a. Systolic: mmhg b. Diastolic: mmhg 4. Anthropometric: a. Weight: b. Waist circumference: kg 1. Lipid profile: a. Total cholesterol: b. HDL-C: c. LDL-C: d. Triglycerides: SECTION 3: INVESTIGATIONS Values Unit 2. Left Ventricular Ejection Fraction: % 1. ASA 2. ADP antagonist 5. LMWH 7. ACE Inhibitor 3. GP receptor inhibitor 8. Angiotensin II receptor blocker c. Hip circumference: cm SECTION 4: MEDICATIONS 9. Statin 10. Other lipid lowering agent 11. Diuretics 4. Warfarin 12. Calcium antagonist 6. Beta blocker 15. Anti-arrhythmic agent SECTION 5: REHABILITATION AND COUNSELLING 1. Was patient referred to cardiac rehabilitation? 2. Has patient stopped smoking? 13. Oral Hypoglycaemic agent 14. Insulin cm NCVD F/U Version 1.7 (last updated on 07/03/06) Page 1 of 1