UK TTP Registry case report form
The UK Thrombotic Thrombocytopenic Purpura (TTP) Registry
Admission Form/Case Report Form | |
|Patient Initials: |DOB: (dd/mm/yy) |Sex: |Ethnic group: |
| | | | |
|Consultant: |Hospital: |Date of hospital admission for this episode: |Date of hospital discharge for this episode: |
| | |(dd/mm/yy) |(dd/mm/yy) |
| | | | |
|First Episode of TTP? |Y |N |Date of this TTP diagnosis | |
|Family History |Y |N |Affected Relative | |
|of TTP? | | | | |
|Relapsed TTP? |Y |N |Number of previous episodes: | |
|Previous treatment (if applicable): |
|Number of PEX to remission: | |
|Immunosuppression: | |
|Outcome: |
|Alive or Died: |A |D |Post mortem result: |
| | | | |
|Past medical history: | |
|Medication prior to admission with TTP: | |
|Any of these medications started within the preceding 6 months? | |
|Symptoms/ Signs: |Y |N |Details: |
|Petechiae, bruising, bleeding | | | |
|Neurological (eg headache, confusion, personality change, | | | |
|sensorimotor loss, seizures) | | | |
|Fever | | | |
|Renal impairment | | | |
|Abdominal (eg pain, nausea, vomiting) | | | |
|Cardiac( eg chest pain, arrhythmias, ECG changes) | | | |
|Other Symptoms/Admission details: | |
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|Patient Initials: | |DOB (dd/mm/yy): | |
|Precipitant: |Y |N |Details: |
|Date of 1st Plasma exchange: | |
|Number of plasma exchange to platelets >150 x109/L | |
|Total Number of plasma exchanges: | |
|Total Number of red cells transfused: | |
|Adjunctive treatment: |Y |N |Details (with dates dd/mm/yy): |
|Steroids | | | |
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|Rituximab | | | |
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|Ciclosporin | | | |
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|Other: | | | |
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|Type of apheresis: (please circle) |Plasma exchange/cell separation/haemofiltration |
|ITU Admission: |Y |N |Please give dates (dd/mm/yy) and details: |
| | | | |
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|Patient Initials: | |DOB (dd/mm/yy): | |
| | | | |On Discharge |Remission sample |
| |On diagnosis |Day 7 |Day 14 | | |
|WBC | | | | | |
|Plt | | | | | |
|Reticulocyte count | | | | | |
|LDH (IU/L) (normal range) | | | | | |
|Urea | | | | | |
|Creatinine (mmol/L) | | | | | |
|Bilirubin (µmol/L) | | | | | |
|Alk phosphatase | | | | | |
|ALT (or AST – please specify) | | | | | |
|CRP | | | | | |
|Film – red cell fragments | |Any additional investigations/results: |
|DAT | | |
|PT (s) | | |
|APTT (s) (with normal range) | | |
|Fibrinogen | | |
|Troponin T (or I – please specify) | | |
|Hep A, B C | | | | |
|HIV | | |
|C3/C4 | | | |
|Rheumatoid factor /ANA /autoantibodies | | | | |
|Anti-cardiolipin Ab’s/ Lupus anticoagulant | | | |
|Blood Group | | |
|Pregnancy test (Positive/negative) | | |
|Other tests-please specify | | |
|Central venous access used? Yes / No |Number of lines inserted: ________lines |
|Position: | |Date: | |
|Infection | | | |
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|Venous Thromboembolism | | | |
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|Allergic reaction | | | |
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|Drug Toxicities | | | |
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|Other | | | |
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