A kérdőívet FELVÉTELKOR kell kitölteni · Guide for estimation of the amount: 1 dl beer (4.5...

1. Patient personal details

Insurance number:…………………………..

Name:…………………………………………

Date of birth:…………………………………….

Contact number:………………………………..

Gender: Female / Male

Ethnicity/Race: White / Roma / Black / Indian / Asian / Other: …….

Blood type: 0 / A / AB / B RH: positive / negative

Allergie: yes/no, if yes:………………………………

Time of questioning: ………………………………(year, month, day)

Was written consent given? Yes / No

Way of admission: ambulatory/ hospital admission

Patient was admitted for: acute flare of symptoms / scheduled testing or intervention

If the patient was admitted:

Date of admittance:

Date of discharge:

Length of hospital stay:

2. Details from the medical history / Risk factors

Smoking: Yes / No

if yes: amount (cigarettes/day):…………………

For how many years? …………………………

if not:

Did you smoke earlier? yes/no

if yes: amount (pcs/occasion):…………………………………

For how many years?………………………………………

How long ago did you stop smoking? ……………………………….

Alcohol consumption: yes / no

if yes: frequency: occasionally/monthly/weekly/daily

amount (g/day):…………………………………

since when? (years):………………………….

Alcohol consumption in the last 2 weeks: …………………..

if not:

Did you drink alcohol earlier? yes/no

if yes: frequency: occasionally/monthly/weekly/daily

amount (g/occasion):…………………………………

For how many years?………………………………………

How long ago did you stop drinking alcohol?..........................

Country:

City:

Hospital:

Doctor:

Blood sample code:

Date of blood sampling:

Guide for estimation of the amount:

1 dl beer (4.5 vol. %) = ~3.5 g alcohol

1 dl wine (12.5 vol. %) = ~10 g alcohol

1 dl hard drink (50 vol. %) = ~40 g alcohol

Caffeine consumption : yes /no

If yes, in what form do you consume caffeine?

Coffe: yes / no

If yes, how often do you consume coffee? occasionally/monthly/weekly/daily

How much do you consume?....................................

(1 dose = one espresso or long coffe)

Instant Coffee: yes / no

If yes, how often do you consume instant coffee? occasionally/monthly/weekly/daily


(1 dose = one packet)

Tee (black or green): yes / no

If yes, how often do you consume tee? occasionally/monthly/weekly/daily


(1 dose =2 dl)

Energy drink: yes / no

If yes, how often do you consume energy drink ? occasionally/monthly/weekly/daily


(1 dose = 2,5 dl)

Coca-cola: yes / no

If yes, how often do you consume coca-cola? occasionally/monthly/weekly/daily


(1 dose =3,3 dl)

Caffeine tablet: yes / no

If yes, how often do you consume caffeine tablet? occasionally/monthly/weekly/daily

How many do you consume?....................................

(1 dose =1 tablet= 100 mg)

Drug abuse: yes/no Prescribed medication should not be included here.

If yes, what kind of drug did you consume?

Party drugs: (pl. Amfetamin, Ecstasy, Gina, Mefedron): yes/no

If yes, how much did you take? …………………How many years ago?……………

Light drugs: (LSD, Marihuana, Hasis): yes/no


Hard drugs: (Crack, Heroin, Kokain, Ópium): yes/no


Medicines: (Diazepám, Ketamin, Kodein): yes/no


Designer drugs: (Mefedron, szintetikus cannabinoidok): yes/no


Diabetes mellitus: yes/no

If Yes: type I. / type II / type III. / MODY

Date of diagnose (date: year)……………………………….

Oral contraceptive usage: yes/no

If yes, when did you take oral contraceptives? before IBD diagnosis/ at the time of IBD

diagnosis

If yes, total duration of Oral contraceptive usage………. (in months)

NSAID usage (longer than 2 weeks): yes/no

If yes, when did you take NSAID? before IBD diagnosis/ at the time of IBD

diagnosis/currently

Usage of antibiotics: yes/no

If yes, when did you take NSAID? before IBD diagnosis/ at the time of IBD

diagnosis/currently

Appendectomy: yes/no

If yes, when did you have appendectomy? ..................................... (date: year)

Previous surgeries not related to IBD: yes/no

If yes, 1. type of surgery:...........................date of surgery:......................(year, month)

2. type of surgery:...........................date of surgery:......................(year, month)

Family history: first degree realtive: Yes / No

If Yes: relative 1. UC / CD, which relative: father / mother / sibling / child

relative 2. UC / CD, which relative: father / mother / sibling / child

Highest level of education: elementary school / vocational school /secondary school / college

/ university

Comorbidities:

Comorbidity 1. :…………………….

Date of diagnosis:…………(year)

drug treatment: Yes / No

if yes, name(s) and dose(s) of the used medication(s) :………………………

surgical treatment: Yes / No

If yes, type of surgery:……………….

Comorbidity 2. :…………………….

Date of diagnosis:…………(year)

drug treatment: Yes / No

if yes, name(s) and dose(s) of the used medication(s) :………………………

surgical treatment: Yes / No

If yes, type of surgery:……………….

Autoimmun disease? Yes / No

If Yes, the diagnosis: Hashimoto thyreoiditis /Addison-syndroma/ Sjögren-

syndrome/ Szisztémás lupus erythematosus (SLE)/ Rheumatoid arthritis (RA)/ coeliakia/

other:……

3. Data on the diagnosis

Date of diagnosis (year, month): ……………………………

Start of symptoms (year, month): ………………………......

Patient’s age at the diagnosis: ………………

The name of the gastroenterologist who established the diagnosis:…………………………

The workplace of the gastroenterologist who established the diagnosis:

hospital (county/urban) /clinic / polyclinic / private practice

Where did the patient live at the time of the diagnosis? city / village

Diagnosis was based on:

3.1. Symptoms: Yes / No

If yes, symptoms occurring at the time of the diagnosis:

abdominal pain / nausea / vomiting / subfebrility / fever / loss of weight / diarrhea / bloody stool/

mucous stool/ fistula / extraintestinal manifestation

If there was extraintestinal manifestation, name it: eye symptom / skin symptom / joint symptom

/ thromboembolism / osteororosis / liver symptom

CD with fistula: Yes / No

If yes,

type os the Fistula: simple / complex

localization of the Fistula: perianal / rectovaginal / entero-enteral / enterocutan /

enterovesical

Determination of Fistula Type: physical state / endoscopy/ images of the pelvic: (MRI /

Ultrasound)/ EUA: rectal examination in anesthesia

Number of fistula:………(piece)

3.2. Laboratory findings: Yes / No

If yes, laboratory findings at the time of the diagnosis: elevated CRP / elevated WBC /

accelerated ESR/ anaemia / iron deficiency / abnormal liver functions / low albumine level

3.3. Endoscopy: Yes / No

Date of the first endoscopy (on which the diagnose was based):………...(year, month)

(uploading result is mandatory)

* quality checkpoint*

Ileo-colonoscopy: Yes / No

If yes, affected segment (s) of the bowels: Ileum / right colon /colon transversum /left

colon / Rectum (description can be attached)

Stricture: Yes / No

If yes, the lovalisation of the stricture: Ileum / right colon /colon transversum /left colon

/ Rectum

Oesophagogastroduodenoscopy: Yes / No

If yes, affected segment (s) of the bowels: esophagus / gastric /duodenum (description can

be attached)

If yes, the lovalisation of the stricture: esophagus / gastric /duodenum

Capsule Endoscopy: Yes / No

If yes, findings:……………… (description can be attached)

3.4. Histological findings: Yes / No (description can be attached)

3.5. Imaging findings: Yes / No

Abdominal ultrasound: Yes / No / no data

If yes, the result: negative / abnormality

Name the abnormality: free abdominal fluid / thickness of the intestinal wall /

abscess / bowel conglomerate / abnormality of the liver / other (e.g: tumor)

The localization of the intestinal wall thickness: duodenum/ small bowels /

coecum/colon ascendens/ colon transversum/ colon descendens/ sigmoid

Name the abnormality of the liver: dilatation of the bile ducts / diffuse lesion of

the liver parenchyma

(description can be attached)

Abdominal X-ray: Yes / No / no data


Name the abnormality: perforation /ileus / passage disturbance/ other (e.g: tumor)

Abdominal CT: Yes / No / no data









CT-enterography/enteroclysis: Yes / No

If yes, findigs:……………………………. (description can be attached)

Abdominal MRI: Yes / No / no data









MR-enterography/enteroclysis: Yes / No


MRCP: Yes / No / no data


Name the abnormality: intrahepatic PSC / extrahepatic PSC / chronic pancreatitis

/ cholangiocarcinoma

Liver biopsy: Yes / No / no data


Name the abnormality: PSC /cholangiocarcinoma/ steatosis hepatis / other (e.g:

tumor)

EUS (rectal): Yes / No / no data


Name the abnormality: fistula / abscess/ other (e.g: tumor)

3.6. IBD related surgical interventions: Yes / No / no data

If yes,

1. type of the surgery: Proctocolectomy + IPAA / proctocolectomy + ileostomy / right

hemicolectomia + ileumresection / segmental resection / stricturo-plastica / abscess

exploration / fistulotomy / seton drenage/ fistulotomy +seton drenage

The localisation of the resection:………………..

Description of the surgery:…………………… (description can be attached)

Histology:………………………… (description can be attached)



exploration / fistulotomy / erspdrenage/ fistulotomy +seton drenage




Montreal classification at the time of the diagnosis:

Age: A1: under 17 years / A2: between 17 and 40 years / A3: over 40 years

Localisation: L1: ileum / L2: colon / L3: ileum and colon / L4: isolated upper GI

Behavior: B1: non- stricturing, non- penetrating / B2: stricturing / B3: penetrating

4. Events since the establishment of a diagnosis

How many gastroenterologist have treated the patient so far? ……………(piece)

If the diagnosis was established in the childhood, how did the patient get to the adult

gastroenterologist?

transitional care: Yes / No

If yes, the number of joint visits: …(piece)

transfer: Yes / No

If yes, did telephone consultation happened between the pediatrician and the adult

gastroenterologist? Yes / No

Did the patient have any relapse since the establishment of the diagnosis? (apart from the

disease activity at the time of diagnosis)? Yes / No

If yes, how many rekapse did the patient have? 1/ 2/ 3/ more than 3

In case of more than 3 relapses, the exact number of relapses:……..(piece)

Did the Montreal classification change sincet he diagnosis? Yes / No

Age: A1: under 17 years / A2: between 17 and 40 years / A3: over 40 years

Localisation: L1: ileum / L2: colon / L3: ileum and colon / L4: isolated upper GI

Behavior: B1: non- stricturing, non- penetrating / B2: stricturing / B3: penetrating

4.1. Therapy (Therapeutic stairs)

Did the patient get 5-ASA drugs? Yes / No

Has any adverse reaction / side effect occurred during the therapy? Yes / No

If yes: allergy / intolerance / nausea / abdominal pain / diarrhea / nephritis / rash of the

skin/ Sweet syndrome / headache /arthralgia /myalgia / Bone marrow depression /

hepatitis / pneumonitis

Did the patient have to stop taking the treatment? Yes / No

If yes, the reason for stopping the treatment: side effect/ adverse reaction/ patient’s

choice/ other: ………

If yes, the date of discontinuation of the treatment: ………. (year, month)

Did the patient get Steroids? Yes / No

Budesonid: Yes / No

If yes, how many times:…….

Methylprednisolon/ prednisolon: Yes / No

If yes, how many times:………


If yes: edema / infection / Cushing syndrome / osteoporosis / diabetes / gastric

ulcer / depression / psychosis / glaucoma / cataracta / increased intracranial pressure/

hypokalaemia / thromboembolism / menstruational disorder / wound healing disorder /

muscle weakness / acute adrenal insufficiency

If there was an infection, what caused it: virus / bacterium/ fungal

Was the patient refractory to steroid treatment? Yes / No

Was the disease steroid-dependent? Yes / No

Did the patient get Immunsupressant drugs? Yes / No

Azathioprine: Yes / No

If yes, the initiation of the treatment:………………….. (year, month)

The date of discontinuation of the treatment: ………. (year, month)


If yes: nausea / vomiting / Bone marrow depression / leukopenia / elevation of

liver enzymes /pancreatitis

The highest applied dose: ……… mg/ttkg

Did the patient get the treatment on the highest applicable dose? Yes / No

If no, the reason for it: nausea / vomiting / Bone marrow depression / leukopenia

/ elevation of liver enzymes /pancreatitis




The result of the Azatioprine treatment: effective / not effective

If it was effective, was the remission proved? Yes / No

If yes, how was the remission proved? endoscopy/ calprotectin/ images (name the image)

6-MP: Yes / No


The date of discontinuation of the treatment: ………. (year, month)


If yes: nausea / vomiting / Bone marrow depression / leukopenia / elevation of

liver enzymes /pancreatitis

The highest applied dose: ……… mg/ttkg

Did the patient get the treatment on the highest applicable dose? Yes / No

If no, the reason for it: nausea / vomiting / Bone marrow depression / leukopenia

/ elevation of liver enzymes /pancreatitis




The result of the 6-MP treatment: effective / not effective



Methotrexate: Yes / No



if yes: Bone marrow depression / mucositis / alopecia / Liver toxicity

The highest applied dose: ……… mg/week




If yes, The date of discontinuation of the treatment: ………. (year, month)

The result of the Methotrexate treatment: effective / not effective



Tacrolimus: Yes / No



If yes: opportunistic infection / deteriorating kidney functions / neurotoxicity /

hyperglykaemia/ gastrointestinal complaint

If there was any opportunistic infection: tuberculosis / fungal infections / other

The highest applied dose: ……… mg/week




If yes, The date of discontinuation of the treatment: ………. (year, month)

The result of the Tacrolimus treatment: effective / not effective



Was the disease persistant despite the immunosuppressive treatment? Yes / No

If yes, did the patient get biological treatment? Yes / No

If yes, what was the first biological agent: Remicade / Inflectra / Humira /Entyvio / Stelara


What viewpoints were taken into account when choosing from the available biological drugs?

Patient’s preference / doctor’s preference / common decision / financing reasons / other:…..

Was there:

side effect/ adverse reaction: Yes / No

if yes: upper respiratory tract infection / tuberculosis / invasive fungal infection / hepatitis

B-reactivation / bakterial sepsis / infusion reaction

Primary nonresponse: Yes / No

Secondary loss of response: Yes / No

if yes, date: ……… (year, month)

cause of secondary loss of response: ………………………

Was dose escalation needed during the treatment? Yes / No

if yes, date: ….………(year, month)

Method of dose escalation? increase dose / increase frequency

How long did the patient get the raised dose?................... (year, month)

Was there a need for strating a non-biological drug beside the biological treatment? Yes / No

If yes, which drug was given? steroid/ immunomodulator/5-ASA

Was surgical intervention needed during the biological therapy? Yes / No

The result of the biological treatment: effective / healed mucosa / not effective

Did the patient have to stop the biological treatment? Yes / No

If yes, why: side effect / Primary nonresponse / Secondary loss of response / financing

reasons / other

Was there a need to change to a second biological therapy? Yes / No

If yes, the name of the chosen second biological therapy: Remicade / Inflectra / Humira /Entyvio

/ Stelara


What viewpoints were taken into account when choosing from the available biological drugs?

Patient’s preference / doctor’s preference / common decision / financing reasons / other:…..

Was there:

side effect/ adverse reaction: Yes / No

if yes: upper respiratory tract infection / tuberculosis / invasive fungal infection / hepatitis

B-reactivation / bakterial sepsis / infusion reaction

Primary nonresponse: Yes / No

Secondary loss of response: Yes / No

if yes, date: ……… (year, month)

cause of secondary loss of response: ………………………

Was dose escalation needed during the treatment? Yes / No

if yes, date: ….………(year, month)

Method of dose escalation? increase dose / increase frequency

How long did the patient get the raised dose?................... (year, month)

Was there a need for strating a non-biological drug beside the biological treatment? Yes / No

If yes, which drug was given? steroid/ immunomodulator/5-ASA

Was surgical intervention needed during the biological therapy? Yes / No

The result of the biological treatment: effective / healed mucosa / not effective

Did the patient have to stop the biological treatment? Yes / No

If yes, why: side effect / Primary nonresponse / Secondary loss of response / financing

reasons / other

Was there a need to change to a third biological therapy? Yes / No

Did the patient received biological agent in a clinical trial? Yes / No

If yes, the name of the test formula:………………………….

Did the patient receive any feeding formula? Yes / No

If yes, the way of formula intake: enteral/parenteral

If it was enteral nutrition, the type of enteral nutrition: exclusive enteral nutrition / additional

enteral nutrition

The name of the applied formula:………….Duration of the nutrition:………….. (months)

Was iron substitution needed? Yes / No

If yes, the name of the applied iron substitution:...........................

The way of intake: intravenous /per os

4.2. Endoscopy

The result of the last endoscopy since the diagnosis:

Ileo-colonoscopy:

The date of the endoscopy:………………………(year, month, day)

Indication of the endoscopy: appearance of acute symptoms / planned control examination /

planned intervention

Ileo-colonoscopy (SES-CD; simple endoscopic score for CD):

Ileum:

SES-CD score: evaluable If it is evaluable, the score is:…………….

not evaluable

If it is not evaluable, the reason: resected / can not be examined due to

stenosis / can not be examined due to technical reasons / contaminated

If the SES-CD score can not be detemined: inflammation/erosion/ulcer/stricture

Right colon: SES-CD score: evaluable If it is evaluable, the score is:…………….

not evaluable




Colon Transversum: SES-CD score: evaluable If it is evaluable, the score is:…………….

not evaluable




Left colon: SES-CD score: evaluable If it is evaluable, the score is:…………….

not evaluable




Rectum:


not evaluable




Size of the ulcer (in cm): 0 – no ulcer, 1 –0,1-0,5 cm, 2- 0,5-2 cm, 3 –>2cm

Ulcerated surface: 0 – no ulcer, 1 - <10%, 2 – 10-30%, 3 - >30%

Surface affected: 0 – nincs, 1 - <50%, 2- 50-75%, 3 - >75%

Stricture: 0- no sticture, 1- one stricture, possible to get through, 2 –

more sticture, possible to get through, 3 – not possible to get

through

SES-CD score of the lower GI tract:……………….. pont

inactive: score 0–3; mild: score 4–10; moderately severe: score11–19; severe: score ≥20.

Operated intestines: Yes / No

If yes: Rutgeerts score (judgment of the endoscopic postoperative recurrence):

RS 0 – no endoscopic recurrence / RS 1 - ≤5 aphtosus lesion / RS 2 - >5 aphtosus lesion

/ RS 3 – diffuse aphtosus ileitis / RS 4 – diffuse inflammation with ulcers and/or stricture

Does the patient have stoma? Yes / No

Was the examination performed through the stoma? Yes / No

Pouchoscopia? Yes / No

If yes: Size of the ulcer (in cm): 0 – no ulcer, 1 –0,1-0,5 cm, 2- 0,5-2 cm, 3 –>2cm





through

Oesophagogastroduodenoscopy

The date of the endoscopy:………………………(year, month, day)

Indication of the endoscopy: appearance of acute symptoms / planned control examination /

planned intervention

Oesophagogastroduodenoscopy (SES-CD): Yes / No

If yes:

Esophagus:


not evaluable




Gastric:


not evaluable




Duodenum:


not evaluable




Size of the ulcer (in cm): 0 – no ulcer, 1 –0,1-0,5 cm, 2- 0,5-2 cm, 3 –>2cm





through

SES-CD score of the upper GI tract:………………..pont

Histology: Yes / No (description can be attached)

Was endoscopic intervention performed? Yes / No / no data

If yes, was endoscopic dilatation performed? Yes / No

If yes, the localisation of the dilatated segment: rectum / colon /small intestines/

anastomosis / upper GIT

Was ERCP performed? Yes / No

If yes, the indication of the ERCP: choledocholithiasis / PSC / stricture

If yes, was any intervention performed? Yes / No

If yes, name the intervention: EST/endobiliar stent implantation

If stent was implanted, hogy many: ……. (piece)

4.3 Surgical interventions performed since the diagnosis

Surgeries Not related to IBD after the diagnosis Yes / No

If yes, 1. type of surgery:...........................date of surgery:......................(year, month)

2. type of surgery:...........................date of surgery:......................(year, month)

Surgeries related to IBD after the diagnosis Yes / No

If yes,













4.4. The last permormed imaging tests from the establishment of the diagnosis to the

present

Abdominal ultrasound: Yes / No / no data









Abdominal X-ray: Yes / No / no data


Name the abnormality: perforation /ileus / passage disturbance/ other (e.g: tumor)

Abdominal CT: Yes / No / no data









CT-enterography/enteroclysis: Yes / No


Abdominal MRI: Yes / No / no data









MR-enterography/enteroclysis: Yes / No


MRCP: Yes / No / no data


Name the abnormality: intrahepatic PSC / extrahepatic PSC / chronic pancreatitis

/ cholangiocarcinoma

EUS (rectal): Yes / No / no data

Capsule Endoscopy: Yes / No

If yes, findings:……………… (description can be attached

4.5. Other additional event/examination since the diagnosis

Did the patient get transfusion? Yes / No

If yes, how many units:............... (piece)

Functional examinations: Yes / No

lactose intolerance:Yes / No

If yes, the result: positive/ negative

lactulose intolerance: Yes / No


other tests: Yes / No

If yes, the name of the test:………..


Did the patient visit psychologist? Yes / No

If yes, with what kind of problem did the patient go to the

psychologist?...........................................

Started medication: Yes / No

If yes, name and dose of the drug:………………….

Started non-medical treatment: Yes / No

If yes, name the non-medical treatment:……………………..

Was the patient vaccinated? Yes / No

If yes, what kind of vaccination did the patient get? flu/ HPV/ Hepatitis A/ Hepatitis B/

Pneumucoccus/Meningococcus/ticks encephalitis vaccine

Was Osteoporosis examined? (DEXA) Yes / No

ha igen, the result:………………… ………………

Started medication: Yes / No

If yes, name and dose of the drug:………………….

Other examination:........................ (name the examination)

TPMT genetics: TPMT*2 (G238C) / TPMT*3A (G460A)/ TPMT*3A (A719G)

Celiac disease immunserology: Yes / No


5. Current Data (At the time of the interview)

5.1. Currently taken medicines

If yes, the name of the drug:………..……….. active

substance:………….……dose:………………... (gramm, milligramm, packet, piece) how many

times per day/ week .................................. way of intake: …………………..(intravenous / per os

/ suppository/ enema)

Other comment: ………………………………………











Does the patient receive any feeding formula? Yes / No

If yes, the way of formula intake: enteral/parenteral

If it is enteral nutrition, the type of enteral nutrition: exclusive enteral nutrition / additional enteral

nutrition

The name of the applied formula:………….Duration of the nutrition:………….. (months)

Is iron substitution needed? Yes / No

If yes, the name of the applied iron substitution:...........................

The way of intake: intravenous /per os

Does the patient keep any kind of diet? Yes / No

If yes, what kind of diet does the patient keep? …..……………………

5.2. Status, present complaints

Weight (kg):……………

Std.weight (kg):……..

Height (m):……………

BMI (kg/m2)………………………………

Body temperature (°C):………..

Present complaints

Number of stool (per week):

Appearance of the stool: normal /bloody / mucous

Consistency of the stool: normal/ loose /hard/ diarrhea

Diarrhea at night? Yes / No

Abdominal complaint: none / cramping / distention / constant

pain

How long does the patient have abdominal complaints?

……………………….. (week)

Anal complaints? Yes / No

Nausea? Yes / No

Vomitting? Yes / No

Swallowing complaints? Yes / No

Breathing complaints? Yes / No

Chest complaints? Yes / No

Urogenital complaints? Yes / No

Conjunctiva? Anaemic / hyperemia/ normal

Edema? Yes / No

Icterus? Yes / No

Cyanosis? Yes / No

Loss of appetite? Yes / No

Loss of weight? Yes / No

Other complaint: …………… ……………………………………………

Activity of the luminális CD: CDAI (Crohn’s disease activity index)

The number of loose stools in the last 7 days

The strength of the abdominal pain: (0 point: no pain; 1 point: mild; 2 points: moderate; 3 points:

severe)/ day

General state (0 point: good; 1 point: appropriate; 2 points: weak; 3 points: bad; 4 points:

intolerable)/ day

Extraintestinal manifestations:

eye symptom: Yes / No

skin symptom: Yes / No

joint symptom: Yes / No

perianal fistula, fissura, abscess: Yes / No

internal fistula: Yes / No

fever (>37,8 C): Yes / No

Usage of obstipants (atropin, difenoxilát, loperamid or other): yes (1 point) /no (0 point)

Presence of Abdominal resistance: none (0 score) / questionable (2 points) /certain (5 points)

Deviation in hematokrit: males (47-htk)

females (42-htk) calculated value(if it is greater than normal, it is 0)

Deviation of the weight: 1-(actual weight/standard weight) (Below -10 count with -10)

CDAI score: ……………………….

<150 Inactive/remission

151-220 mild disease

221-300 moderate disease

301-450 severe disease

>450 very severe - fulminant

Activity of the Fistulazing CD: PDAI (perianal disease activity index):

Discharge: 0 point: - no discharge

1- point: minimal mucous discharge

2- points: Moderate mucous or purulent discharge

3- points: Substantial discharge

4- points: Gross fecal soiling

Pain/ restriction of activities: 0 point: no activity restriction

1- point: Mild discomfort, no restriction

2- point: Moderate discomfort, some limitation

activities

3- point: Marked discomfort, marked limitation

4- point: Severe pain, severe limitation

Restriction of sexual activity: 0 point- No restriction in sexual activity

1- point: Slight restriction in sexual activity

2- points: moderate restriction in sexual activity

3- points: marked restriction in sexual activity

4- points: Unable to engage in sexual activity

Type of the perianal disease: 0 point: no perianal disease/ skin tags

1 point: anal fissure or mucosal tear

2 points: <3 perianal fistulae

3 points: >3 perianal fistulae

4 points: Anal sphincter ulceration or fistulae with

significant undermining of skin

Degree of infiltration: 0 point: no induration

1 point: minimal induration

2 points: moderate induration

3 points: substantial induration

4 points: Gross fluctuance/abscess

PDAI score:……………

Physical examination of the abdomen:

Abdominal tenderness: Yes / No

If yes, please mark the localisation on the figure.

Muscular defense: Yes / No

Abdominal resistance: none/ questionable/certain

If yes, please mark the localisation on the figure.

Liver: normal / enlarged

Abnormalities:……………………..

Spleen: normal / enlarged

Rectal digital examination: normal / abnormal

Fistula: Yes / No

Abscess: Yes / No

Seton: Yes / No

Other physical abnormalities:

Lymph nodes: normal /abnormal

Mouth: aphta / soor / ulcer /normal

Other abnormalities: Yes / No

If yes, specify:…………………………

Description of the physical status:…………………………………………………

5.3. Serum tests

erythrocyte sedimentation rate (mm/h)

CRP (mg/l)

Blood WBC count (G/l) RBC count (T/l)

Hemoglobin (g/l)

Hematokrit (%)

MCV Platelet count (G/l)

Ions

Sodium (mmol/l) Potassium (mmol/l) Calcium (mmol/l) Magnesium (mmol/l)

Phosphate (mmol/l) Chloride (mmol/l) Iron (umol/l)

Pancreas

Glucose (mmol/l) Alfa amilase (U/l) Lipase (U/l)

Renal functions

Urea nitrogen (Karbamid) (mmol/l)

Kreatinin (umol/l)

eGFR

Liver functions Total bilirubin (umol/l)

Direct/conjugated bilirubin (umol/l) Indirect bilirubin (umol/l) ASAT/GOT (U/l) ALAT/GPT (U/l)

Gamma GT (U/l) Alkaline phosphatase (U/l)

Laktate dehydrogenase LDH (U/l)

Protrombin (%)

Protrombin INR

Metabolism

Cholesterol (mmol/l)

Triglicerides (mmol/l)

Uric acid (umol/l)

TSH (mU/l)l

HgbA1C (%)

Proteins

Total protein (g/l)

Albumin (g/l)

Globulin alfa1 (g/l)

Globulin alfa2 (g/l)

Globulin beta (g/l)

Globulin gamma (g/l)

Fibrinogen (g/l)

IBD

Procalcitonin (ng/ml)

IgA (g/l)

IgM (g/l)

IgG (g/l)

Ferritine (ug/l)

Transzferrin saturation (%)

B12 level (pmol/l)

Folic acid (nmol/l)

ASCA IgA

ASCA IgG

ANA

pANCA

IgG4 (g/l)

CEA (ug/l)

CA 19-9 (U/ml)

Infliximab TL (ug/ml)

Adalimumab TL (ug/ml)

Anti-drug antibody (ug/ml)

Anti-drug antibody (ug/ml)

Vvt.6-TGN (pmol/8x108 RBC)

Blood gases

PaO2 (Hgmm)

HCO3 (mmol/l)

sO2 (%)

Other

5.4. Suggestions

Is it possible to discharge the patient? Yes / No

If no, name the reason of hospital admission: severe disease activity / abscess /

perforation / other:…..

if yes,

Was dose modification needed at any of the currently taken drugs? Yes / No

if yes: dose elevation / dose reduction

Which drug’s dose was modified?...........................

New dose of the drug?................................

Was the discontinuation of a currently taken drug needed? Yes / No

If yes, the name of the drug:………..………..

The reason for discontinuing the drug: side effect / intolerance/ infusion reaction

/ Primary nonresponse / Secondary loss of response / financing reasons /

other:………………

Was the initiation of a completely new drug(s) needed? Yes / No


substance:………….……dose:………………... (gramm, milligramm, packet,

piece) how many times per day/ week.................................. way of intake:

…………………..(intravenous / per os / suppository/ enema)

Other comment:………………………………………

The reason for starting a new drug: disease activity / ineffectiveness of the

currently taken drug(s) / due to the patient’s complaints / intolerance of the

currently taken drug(s) / fistula formation

Will it be neccessary to perform any elective intervention in the next 12

months? Yes / No

If yes, what kind of intervention will be performed?

surgery / drainage / seton / endoscopic dilatation / upper endoscopy /lower

endoscopy

1. name and date of the intervention:…………………………………………

2. name and date of the intervention:…………………………………………

Will it be neccessary to perform any images in the next 12 months? Yes / No

If yes, what kind of images will be performed?

endoscopy / abdominal ultrasound / MRI / CT /Endoscopic ultrasound / ERCP

/MRCP

1. name and date of the image:…………………………………………

2. name and date of the image:…………………………………………

A kérdőívet FELVÉTELKOR kell kitölteni · Guide for estimation of the amount: 1 dl beer (4.5...

Documents

Transcript of A kérdőívet FELVÉTELKOR kell kitölteni · Guide for estimation of the amount: 1 dl beer (4.5...