[ ] UKITP INITITAL INFORMATION SHEET (2.2) July 9, 2010

[ ] UKITP INITITAL INFORMATION SHEET (2.2) July 9, 2010

[UKITP INITITAL INFORMATION SHEET (2.2)] July 9, 2010
Barts and The London
The Royal London Hospital
Pathology and Pharmacy Building
80 Newark Street, London E1 2ES
Centre for Haematology
Institute of Cell and Molecular Science
Dr Drew Provan
Senior Lecturer in Haematology
Tel:
+44-(0)-203-246-0335
Fax:
+44-(0)-203-246-0351
Email: [email protected]
Registration Information Sheet
UK Adult Idiopathic Thrombocytopenic Purpura (ITP) Registry
I.
Demographic Information
A. Registration Information-Key Dates:
1. Registration Date
______/_____/_____
Day
Month
Year
2. Diagnosis Date
______/_____/_____
3. Date of Last Clinic Visit
______/_____/_____
Day
Day
Month
Month
B. Patient Information:
4. Surname
_______________________________
5. Forename(s)
_______________________________
6. Gender
male
female
7. Date of Birth
______/_____/_____
8. Address
_______________________________
Day
Month
Year
Address Line 1
_______________________________
Address Line 2
_______________________________
City/Town
_______________________________
Post Code
C. Hospital & Consultant Information:
9. Hospital Name
_______________________________
10. Departmental Address
_______________________________
Address Line 1
_______________________________
Address Line 2
_______________________________
City/Town
_______________________________
Post Code
11. Consultant Name
_______________________________
Year
Year
[UKITP INITIAL INFORMATION SHEET (2.2)] July 9, 2010
II. Clinical Information
A. Patient Weight (Time of Diagnosis):
12. ____________kg
B. Platelet Counts:
13.
C.
Date (day/month/year)
9
Count (×10 /L)
Bleeding Events:
Location
14.
Cutaneous Bleeds
15.
Bleeds from the Oral Cavity
16.
Epistaxis
17.
Uterine Bleeds
18.
Haematuria
19.
Gastrointestinal Bleeds
20.
Intracranial Haemorrhage
21.
Muscle Bleeds
22.
Joint Bleeds
23.
Subconjunctival Bleeds
24.
Retinal Bleeds
Occurrence
Presentation Date(s)
____/____/____
____/____/____
____/____/____
____/____/____
____/____/____
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[UKITP INITIAL INFORMATION SHEET (2.2)] July 9, 2010
D. Treatments:
Treatment
25.
Prednisolone
26.
IVIg
27.
Splenectomy
Administered
Date(s)
Dosage(s)
Course
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
_______
_______
_______
_______
________
________
________
________
Laparoscopic
28.
Anti-D
___/___/___
___/___/___
_______
_______
________
________
29.
Cyclic High-Dose Methylprednisolone
30.
Dexamethasone
31.
Danazol
32.
Dapsone
33.
Azathioprine
34.
Cyclophosphamide
35.
Vinca Alkaloids
36.
Mycophenolate
37.
Eltrombopag
38.
Romiplostim
_______
_______
_______
_______
_______
_______
_______
_______
_______
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________
39.
Plasmaphersis
40.
Protein A Immunoadsortion
41.
Interferon
42.
Cyclosporine
43.
Rituximab
Platelet Transfusion
45.
Red Blood Cell Transfusion
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
________
________
________
________
________
________
44.
46.
H. pylori Treatment
47.
Vitamin C Supplements
48.
Other
___/___/___
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_______
_______
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________
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________
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[UKITP INITIAL INFORMATION SHEET (2.2)] July 9, 2010
E. Co-Morbid Conditions
49.
Condition
Cataracts
Occurrence
Diagnosis Date
____/____/____
50.
Osteoarthritis
____/____/____
51.
Type-II Diabetes
____/____/____
52.
Hypertension
____/____/____
53.
Peptic Ulcers
____/____/____
54.
H. pylori Infection
____/____/____
55.
Renal Failure/Impairment
____/____/____
56.
Chronic Liver Disease
____/____/____
57.
Myocardial Infarction
____/____/____
58.
Ischaemic Stroke
____/____/____
59.
Transient Ischaemic Attack
____/____/____
60.
Unstable Angina
____/____/____
61.
Deep Vein Thrombosis
____/____/____
62.
Pulmonary Embolism
____/____/____
63.
Splenomegaly
____/____/____
64.
Thyroid Disease
____/____/____
65.
Depression/Anxiety
____/____/____
66.
Miscarriage
____/____/____
67.
Cushing’s Syndrome
____/____/____
68.
Candida Infection
____/____/____
69.
Pneumonia
____/____/____
70.
Other Autoimmune Disease
____/____/____
71.
Haematological Malignancy
____/____/____
72.
Solid Tumour/Malignancy
____/____/____
73.
Photoxicity
____/____/____
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[UKITP INITIAL INFORMATION SHEET (2.2)] July 9, 2010
F. Biochemical Information (Time of Diagnosis):
Serum Level
74. Alanine Transaminase (ALT)
____________
75. Aspartate Transaminase (AST)
____________
76. Alkaline Phosphatase (ALP)
____________
77. Bilirubin
____________
G. Haematological Information (Time of Diagnosis Except Where Noted):
Performed
Result
Rh(D)
78. Blood Group
A
B
A/B
O
+
79. Mean Platelet Volume (MPV)
________________________
80. Red Blood Cells (RBC)
________________________
81. White Blood Cells (WBC)
________________________
82. Haemoglobin (Hb)
________________________
83. Haemoglobin (Hb) [Last Available]
________________________
84. Neutrophils
________________________
85. Neutrophils [Last Available]
________________________
-
86. Direct Agglutination Test (DAT)
Positive
Negative
87. Marrow Aspirate
Conclusion:__________________
88. Trephine Biopsy
Conclusion:__________________
H. Immunological Information (Time of Diagnosis)
Performed
Serum Level
89.
IgG
__________
90.
IgA
__________
91.
IgM
__________
92.
Anti-nuclear Antibodies (ANA)
__________
5
[UKITP INITIAL INFORMATION SHEET (2.2)] July 9, 2010
I. Coagulation Information (Time of Diagnosis)
Performed
Serum Level/Percentage
93.
Prothrombin (PT) Ratio
94.
Activated Partial
Prothrombin Time (APPT)
95.
Lupus Anticoagulant (LA)
__________
96.
IgG-Anticardiolipin Antibodies (aCL)
__________
97.
IgM-Anticardiolipin Antibodies (aCL)
__________
98.
Reticulocyte Percentage
__________
Time/Ratio
__________
__________
J. Miscellaneous
Performed
99.
t80%/t30 Minutes Spleen/Liver Ratio
Conclusion:
__________
__________________
Indium Scanning
___________________
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