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: |

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|Consultant: |Hospital: |Date of hospital admission for this episode: |Date of hospital discharge for this episode: |

| | |(dd/mm/yy) |(dd/mm/yy) |

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|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: |

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|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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