3. Chart Number: 4. 9IS #: (UNOS use only) Father's I/C. I/C Guardian: Not available. (autofill if MyKad is available)

Transcription

1 provided, check ( ) one box only. NA refers to t Applicable. Fill in the date with ddmmyyyy format. SECTION 1 : PROVIDER INFORMATION 1a. Transplant Centre Provider Number: 1b. Transplant Centre Name : 2a. Follow-up Hospital Provider Number: 2b. Follow-up Hospital Name: 3. Chart Number: 4. 9IS #: (UNOS use only) SECTION 2 : RECIPIENT DETAILS 1. Name : (Please print in capital letters) 2. Registration Number: 3. NRIC : MyKad: - - Old IC: Other ID document : Specify document type (if others): <12 years: Birth cert # : Registration number Passport Mother's IC Father's IC IC Guardian: Mother Father Armed Force ID Work Permit # Date of Birth Lab number Sibling ranking: Others 4a. Date of Birth: 6. Ethnic group: If the exact date is not known, please enter 0107yyyy Malay Chinese Indian 7. Religion: Islam Buddhism Bumiputra Sabah, specify: (autofill if MyKad is available) 4b. Age: (autocalculate) Bumiputra Sarawak, specify: Others, specify:. 5. Gender: Male Female Christianity Hinduism Others, specify 8. Marital Status: Single Married Widowed Divorced 9. Education Level: Uneducated Primary Secondary Tertiary Others, specify 10. Date added to wait list: 11. Date of transplant: 12. State of residence: 13. Country of residence: 14. Immediate Pretransplant Employment status: Johor Darul Takzim Kedah Darul Aman Kelantan Darul Naim Melaka Negeri Sembilan Darul Khusus Pahang Darul Makmur Perak Darul Ridzuan Perlis Indera Kayangan Pulau Pinang Sabah Sarawak Selangor Darul Ehsan Terengganu Darul Iman Wilayah Persekutuan Kuala Lumpur Wilayah Persekutuan Labuan, Sabah Wilayah Persekutuan Putrajaya t applicable - Foreign Malaysia Others, specify : Student Working full time Working Part Time By Choice Working Part Time Due to Disease Working Part Time Reason t Working By Choice t Working Due to Disease SECTION 3 : IMMEDIATE PRETRANSPLANT CLINICAL INFORMATION 1. ABO Blood Group: 2. Weight (kg): 3. Height (cm): 4a. Heart diagnosis: t Working Unable to Find Employment A B AB O.. Ischaemic Cardiomyopathy Idiopathy Dilated Cardiomyopathy Other, specify Restrictive Cardiomyopathy End Stage valvular heart disease t Working, Reason Retired Employment Status Hypertrophic Cardiomyopathy 4b. Lung diagnosis specify: (Use Code) Version 1.11 last updated on Mandatory Fields Page 1

2 provided, check ( ) one box only. NA refers to t Applicable. Fill in the date with ddmmyyyy format. SECTION 3 : IMMEDIATE PRETRANSPLANT CLINICAL INFORMATION 5a. Medical condition: 5b. Patient on life support: (Continue) Patient in Intensive Care Uni Hospitalized, but not in Intensive Care Unit t hospitalized ECMO IABP hrs hrs PGE IV Inotropes Nasal Ventilation ninvasive Ventilation, CPAP ninvasive Ventilation, BiPAP Long Term Oxygen Therapy Other mechanism Specify: LVAD HeartMate IP HeartMate VE HeartMate II vacor PC vacor PCq Thoratec Arrow Lionheart HeartSaver VAD Micromed DeBakey Jarvik 2000 Pittsburgh AB180 Berlin Heart Medos Toyobo Type unspecified RVAD Thoratec Berlin Heart Medos Toyobo Abiomed BVS BioMedicus Type unspecified TAH Cardiowest AbioCor Type unspecified 5c. Date of implantation: 6. Functional Status: (How does the patient perform activities of daily living? Select one) activity limitations. (NYHA Class I or Class II) Performs activities of daily living with some assistance. (NYHA Class III) Performs activities of daily living with total assistance. (NYHA Class IV) NA Patient hospitalized 7. Pretransplant Serology: a. HIV Negative Positive b. CMV lgg: Negative Positive lgm: DNA: Negative Positive Negative Positive c. Hep B Core Antibody: Negative Positive Surface Antigen: HBV DNA: Negative Positive Negative Positive d. Hep C Antibody Screen: Negative Positive RIBA Test: HCV RNA: Negative Positive Negative Positive e. EBV IgG: Negative Positive lgm: DNA: f. Most recent Hemodynamics & Inotropes PA (sys) actual: PA (dia) estimate: PA (mean): PCW (mean): CO: Ejection Fraction: Negative Positive Negative Positive mmhg mmhg mmhg mmhg Lmin % Inotropes Inotropes Inotropes Inotropes Inotropes Inotropes Version 1.11 last updated on Mandatory Fields Page 2

3 provided, check ( ) one box only. NA refers to t Applicable. Fill in the date with ddmmyyyy format. SECTION 3 : IMMEDIATE PRETRANSPLANT CLINICAL INFORMATION 8a. Most recent Serum Creatinine: 8b. Most recent Serum Total Bilirubin: 8c. Oxygen requirement at rest: 8d. Chronic Steroid Use: µmoll µmoll Lmin (Continue) 8e. FEV1(L)FVC(L): 8f. po 2 on room air: on oxygen: 9. Pulmonary Status a. FVC: 10. General Medical Factors b. FEV1: c. pco2: % Predicted % Predicted mmhg a. Diabetes Diabetes Insulin Dependent Diabetes n-insulin Dependent Diabetes b. Dialysis Dialysis Hemodialysis c. Peptic Ulcer Disease, Drug Treated, t Drug Treated Diabetes, Dependency Peritoneal Dialysis, Drug Treatment 11. Heart Medical Factors d. Unstable Angina Coronary Artery Disease Myocardial Infarction: e. Drug Treated Systemic Hypertension: f. Symptomatic Cerebrovascular Disease Stable CAD Unstable CAD Old MI g. Symptomatic Peripheral Vascular Disease h. Drug Treated COPD i. Pulmonary Embolism (within last 6 months) j. Any Previous Transfusions : k. Any Previous Malignancy (Exclude non-melanoma skin cancer) l. PRA Negative Positive m. Any cigarette use within last 6 months a. Sudden Death b. Antiarrythmics c. Amiodarone d. Implantable defibrillator e. Cardiac Resynchronisation Therapy f. Exercise oxygen consumption: mlminkg Version 1.11 last updated on Mandatory Fields Page 3

4 provided, check ( ) one box only. NA refers to t Applicable. Fill in the date with ddmmyyyy format. SECTION 3 : IMMEDIATE PRETRANSPLANT CLINICAL INFORMATION (Continue) 12. Events Occuring to Listing for Transplant a. Pneumothorax b. Infection requiring IV drug therapy (within two weeks prior to listing) c. Left ventricular remodeling d. Pneumoreduction e. Transmyocardial revascularization (TMR) f. Sternotomy ne 1 +1 g. CABG h. Thoracotomy: Left i. Thoracotomy: Right j. Pleurodesis 13. Lung Medical Factors a. IV Treated Pulmonary Sepsis Episodes > 2 in last 12 months 14. HLA Typing: a. Method: b. Corticosteroid Dependency > 5 mgday c. Six minute walk distance < 150 ft. d. Pan-Resistant Bacterial Infection b. Typing: Serology DNA Other, specify: SECTION 4 : TRANSPLANT CLINICAL INFORMATION 1. Multiple Organ Recipient: check all organs that apply Liver Kidney Intestine Pancreas Pancreas Islets Bone Marrow 2a. Procedure Type: Ortho Heart Hetero Heart 2b. Procedure Information (Heart only): Orthotopic Bicaval Orthotopic Traditional Heart Lung Single Left Lung Single Right Lung Bilateral Sequential Lung Heterotopic En-Bloc Double Lung Others: 3. Total Organ Ischaemic Time: Heart Left Lung Heart - Lung Right Lung SECTION 5 : POST TRANSPLANT CLINICAL INFORMATION 1. Events Prior to Discharge: a. Any Drug Treated Rejection b. Any Drug Treated Infection c. Stroke d. Dialysis e. Re-Operation, Hemorrhage f. Re-Operation, Other g. Other Surgical Procedures h. Prolonged Graft Dysfunction i. Permanent Pacemaker j. Bronchopleural Fistula k. Airway Dehiscence Version 1.11 last updated on Mandatory Fields Page 4

5 provided, check ( ) one box only. NA refers to t Applicable. Fill in the date with ddmmyyyy format. SECTION 6 : PATIENT STATUS AT DISCHARGE 1. Patient Status a. Date of Report or Death b. Status: Living Dead Cause of Death: (Use code) Specify: Retransplanted prior to hospital discharge Ca Hyperacute Rejection Acute Rejection Other Lost 2. Transplant Hospitalization a. Date of discharge from transplant center b. Date of admission to transplant center c. Was patient transferred from another hospital prior to transplant? Date of admission to transferring hospital 2. Previous transplants? Kidney : Liver : Pancreas (whole) Pancreas (islet cells) Heart : : : Lung Intestine : : Bone Marrow : Version 1.11 last updated on Mandatory Fields Page 5

6 provided, check ( ) one box only. NA refers to t Applicable. Fill in the date with ddmmyyyy format. SECTION 7 : TREATMENT AT DISCHARGE 1. Immunosuppressive Information a. Did the patient participate in any clinical research protocol for immunosuppressive medications? Specify: 2. Other Therapy a. Photopheresis 3. Antivirals b. Plasmapheresis c. Total Lymphoid Irradiation (TLI) a. CMV Globulin b. Acyclovir (Zovirax) c. Ganciclovir (Cytovene) d. Other: SECTION 8 : DONOR INFORMATION 1. Donor's Name: 2. Donor's Age: 3. Donor's gender: Male Female 4. Donor's Ethnic group: Malay 5. Donor's Country: Malaysia Others, specify: 6. Donor Type: Cadaveric Living 7. Date of Organ Procurement 8. Donor's ABO Blood Group Chinese Indian Bumi Sabah Bumi Sarawak Others: A B AB O 9. a) Donor's Weight (kg): 9. b) Donor's Height (cm): 10. Donor's Cause of Death 11. Donor's Mechanism of Death AnoxiaCardiac Arrest Head Trauma Drowning Seizure Drug Intoxication Asphyxiation Cardiovascular Electrical CerebrovascularStroke CNS Tumor Gunshot Wound Stab Blunt Injury Sudden Infant death Other, specify: Intercranial Hemorrhage Stroke Death from Natural Causes 12. Donor's Serology a. Anti-HIV I Negative Positive b. Anti-HIV II c. Anti-HTVL I d. Anti-HTVL II Negative Positive Negative Positive Negative Positive e. RPR-VDRL Negative Positive f. Anti-CMV g. HBsAg h. Anti-HBC i. Anti-HCV j. EBV 13. Donor's HLA Typing: a. Method: Serology DNA b. Typing: Negative Positive Negative Positive Negative Positive Negative Positive Negative Positive Other, specify: 14. Donor's History Of: a. Hypertension b. Diabetes c. Cancer d. Infection at time of Procurement e. Donor Coronary Disease MVA ne of the Above Version 1.11 last updated on Mandatory Fields Page 6

7 provided, check ( ) one box only. NA refers to t Applicable. Fill in the date with ddmmyyyy format. SECTION 9 : IMMUNOSUPPRESSION THERAPY 1. Steroids a. Prednisone b. Methylprednisolone 2. T-Cell Activation Inhibitors a. Cyclosporin A (CSA, Sandimmune, CyA, CyS) b. Neoral (CyA-NOF) c. FK506 (Prograf, Tacrolimus) d. Rapamycin (RAPA, Sirolimus, Rapamune) e. Gengraf 3. Antimetabolites a. Azathioprine (AZA, Imuran) b. Mycophenolate Mofetil (MMF, Cellcept, RS61443) c. Cytoxan (Cyclophosphamide) 4. Anti-Lymphocyte Receptor Antibodies d. Methotrexate (Folex, PFS, Mexate- AQ, Rheumatrex) a. T10B9 (Medimmune) b. ATG (Atgam, Anti-thymocyte Globulin) c. NRATG NRATS d. OKT3 (Orthoclone, Muromonab) e. Thymoglobulin f. Zenepax g. Simulect 5. Cytokine Inhibitors a. IL - 1 Receptor Antagonist b. Anti - IL - 6 c. Anti - TNF d. Soluble IL - 1 Receptor 6. Suppressor Inducers a. Aldesleukin (IL - 2) 7. Others, immunosuppressive medication, specify: Version 1.11 last updated on Mandatory Fields Page 7