Persons using assistive technology may not be able to fully access information in this file. For assistance, e-mail niddk-cr@imsweb.com. Include the Web site and filename in your message. LX LONG-TERM FOLLOW-UP FORM NIDDK Liver Transplantation Database PATIENT ID _________-________________________ ID EVALUATION TIMEPOINT________ ETMPT DATE OF LAST CONTACT _____/______/______ LCM LCD LCY MM DD YY VII. Any MAJOR EVENTS/CONDITIONS since last evaluation? Yes ___ No ___ MAJEV (YN) Cont. from |IF NEW, date |Outcome/ |IF RESOLVED, prev. eval |of first onset |current status|date of (check |this eval period |(see codes on |resolution if yes) |(MM/DD/YY) |opposite page)|(MM/DD/YY) ________________________________ __(YN)________________________(STCODE)________________ 1. CARDIOVASCULAR (YN) CHYPR __ 1.1 Hypertension (treated) HPRP HPROM/HPROD/HPROY HPRSC HPRRM/HPRRD/HPRRY MYOPT __ 1.2 Cardiomyopathy MYOP MYOO/MYOOD/MYOOY MYOSC MYORM/MYORD/MYORY PULHR __ 1.3 Pulmonary hypertension PHRP PHROM/PHROD/PHROY PHRSC PHRRM/PHRRD/PHRRY CVENA __ 1.4 Ventricular arrhythmia VENP VENOM/VENOD/VENOY ENSC VENRM/VENRD/VENRY CCHF __ 1.5 Congestive heart failure CHFP CHFOM/CHFOD/CHFOY CHFSC CHFRM/CHFRD/CHFRY ANGN __ 1.6 Angina ANGP ANGOM/ANGOD/ANGOY ANGSC ANGRM/ANGRD/ANGRY CMYIN __ 1.7 Myocardial infarction MIP MIOM/MIOD/MIOY MISC MIRM/MIRD/MIRY CCARR __ 1.8 Cardiopulmonary arrest CARP CAROM/CAROD/CAROY CARSC CARRM/CARRD/CARRY CVOTH __ 1.9 Other cardiovascular events, specify CVOP CVOOM/CVOOD/CVOOY CVOSC CVORM/CVORD/CVORY ___________________________ CVOS (30 char) CINT ___ 1.10 Coronary intervention Date Type Other, specify (30 char) (MM/DD/YY) (see codes below) (CORINT) CIN1M/CIN1D/CIN1Y CINT1 CINS1 1.10.1 ___/___/___ ____ _______________________________ CIN2M/CIN2D/CIN2Y CINT2 CINS2 1.10.2 ___/___/___ ____ _______________________________ CIN3M/CIN3D/CIN3Y CINT3 CINS3 1.10.3 ___/___/___ ____ _______________________________ CIN4M/CIN4D/CIN4Y CINT4 CINS4 1.10.4 ___/___/___ ____ _______________________________ CIN5M/CIN5D/CIN5Y CINT5 CINS5 1.10.5 ___/___/___ ____ _______________________________ CIN6M/CIN6D/CIN6Y CINT6 CINS6 1.10.6 ___/___/___ ____ _______________________________ CIN7M/CIN7D/CIN7Y CINT7 CINS7 1.10.7 ___/___/___ ____ _______________________________ CIN8M/CIN8D/CIN8Y CINT8 CINS8 1.10.8 ___/___/___ ____ _______________________________ CINM (YN) ______ Check here if additional coronary intervention, and document in COMMENTS section. Use the keywords MORE CARD to precede the comments. VII. MAJOR EVENTS/CONDITIONS since last evaluation (continued): Cont. from |IF NEW, date |Outcome/ |IF RESOLVED, prev. eval |of first onset |current status |date of (check |this eval period |(see codes on |resolution if yes) |(MM/DD/YY) |opposite page) |(MM/DD/YY) ___________________________(YN)______________________________(STCODE)__________________ 2. DIABETES MELLITUS (treated) (YN) DIABD __ 2.1 diet controlled DDP DDOM/DDOD/DDOY DDSC DDRM/DDRD/DDRY DIABO __ 2.2 Oral medication DOP DOOM/DOOD/DOOY DOSC DORM/DORD/DORY DIABI __ 2.3 Using insulin DIP DIOM/DIOD/DIOY DISC DIRM/DIRD/DIRY 3. RENAL INSUFFICIENCY (creatinine > 2.0 mg/dl) RENND __ 3.1 Not requiring dialysis RIP RIOM/RIOD/RIOY RISC RIRM/RIRD/RIRY REND __ 3.2 Requiring dialysis RIDP RIDOM/RIDOD/RIDOY RIDSC RIDRM/RIDRD/RIDRY 4. ABDOMINAL ASCIT __ 4.1 Ascites ASCP ASCOM/ASCOD/ASCOY ASCSC ASCRM/ASCRD/ASCRY VARNB __ 4.2 varices, non-bleeding VARP VAROM/VAROD/VAROY VARSC VARRM/VARRD/VARRY UGIV __ 4.3 Upper GI bleed, variceal GIVP GIVOM/GIVOD/GIVOY GIVSC GIVRM/GIVRD/GIVRY UGINV __ 4.4 Upper GI bleed, non-variceal GINP GINOM/GINOD/GINOY GINSC GINRM/GINRD/GINRY ABLGI __ 4.5 Lower GI bleed LGIP LGIOM/LGIOD/LGIOY LGISC LGIRM/LGIRD/LGIRY GIUNK __ 4.6 GI bleed,unknown GIUP GIUOM/GIUOD/GIUOY GIUSC GIURM/GIURD/GIURY VTHA __ 4.7 Vascular thrombosis – hepatic artery VTHP VTHOM/VTHOD/VTHOY VTHSC VTHRM/VTHRD/VTHRY VTPV __ 4.8 Vascular thrombosis – portal vein _ VTPP VTPOM/VTPOD/VTPOY VTPSC VTPRM/VTPRD/VTPRY PORHR __ 4.9 Portal hypertension PORP POROM/POROD/POROY PORSC PORRM/PORRD/PORRY PVOCC __ 4.10 Portal vein partial occlusion _ PVOP PVOOM/PVOOD/PVOOY PVOSC PVORM/PVORD/PVORY HPS __ 4.11 Hepatopulmonary HPSP HPSOM/HPSOD/HPSOY HPSSC HPSRM/HPSRD/HPSRY CUC __ 4.12 Chronic ulcerative colitis CUCP CUCOM/CUCOD/CUCOY CUCSC CUCRM/CUCRD/CUCRY CROHN __ 4.13 Crohn’s disease CROP CROOM/CROOD/CROOY CROSC CRORM/CRORD/CRORY 5. BILIARY BCHO __ 5.1 Cholangitis (bacterial with fever) BCHP BCHOM/BCHOD/BCHOY BCHSC BCHRM/BCHRD/BCHRY ICHOL __ 5.2 Ischemic cholangitis ICHP ICHOM/ICHOD/ICHOY ICHSC ICHRM/ICHRD/ICHRY BCCL __ 5.3 Choledocho-choledocho (C-C) leak CCLP CCLOM/CCLOD/CCLOY CCLSC CCLRM/CCLRD/CCLRY BCJL __ 5.4 Choledocho-jej (C-J) leak CJLP CJLOM/CJLOD/CJLOY CJLSC CJLRM/CJLRD/CJLRY BTTL __ 5.5 T-tube tract leak/ biliary tube leak TTLP TTLOM/TTLOD/TTLOY TTLSC TTLRM/TTLRD/TTLRY BAS __ 5.6 Anastomotic strictures ASTP ASTOM/ASTOD/ASTOY ASTSC ASTRM/ASTRD/ASTRY BIS __ 5.7 Intra-hepatic strictures ISTP ISTOM/ISTOD/ISTOY ISTSC ISTRM/ISTRD/ISTRY STROB __ 5.8 Strictures/obstruction, NOS STRP STROM/STROD/STROY STRSC STRRM/STRRD/STRRY BSD __ 5.9 Stones/debris DEBP DEBOM/DEBOD/DEBOY DEBSC DEBRM/DEBRD/DEBRY VII. MAJOR EVENTS/CONDITIONS since last evaluation (continued): Cont. from |IF NEW, date |Outcome/ |IF RESOLVED, prev. eval |of first onset |current status|date of (check |this eval period |(see codes on |resolution if yes) |(MM/DD/YY) |opposite page)|(MM/DD/YY) ________________________________ __(YN)________________________(STCODE)________________ 6. NEUROLOGIC NCNS __ 6.1 Cyclosporine neurotoxicity CYNP CYNOM/CYNOD/CYNOY CYNSC CYNRM/CYNRD/CYNRY FKNT __ 6.2 Tacrolimus neurotoxicity FKNP FKNOM/FKNOD/FKNOY FKNSC FKNRM/FKNRD/FKNRY MIGRA__ 6.3 Migraine headaches MIGP MIGOM/MIGOD/MIGOY MIGSC MIGRM/MIGRD/MIGRY NSEIZ __ 6.4 Seizures SEIP SEIOM/SEIOD/SEIOY SEISC SEIRM/SEIRD/SEIRY STROH __ 6.5 Stroke, hemorrhagic STHP STHOM/STHOD/STHOY STHSC STHRM/STHRD/STHRY STRON __ 6.6 Stroke, non-hemorrhagic STNP STNOM/STNOD/STNOY STNSC STNRM/STNRD/STNRY NENCP __ 6.7 Hepatic encephalopathy ____ HENP HENOM/HENOD/HENOY HENSC HENRM/HENRD/HENRY 6.7.1 Specify code for worst stage ______ ENCSS (see codes on opposite page) (ENCEPH) 6.7.2 Onset date for worst stage ____/____/____ HENSM/HENSD/HENSY MM DD YY ENCO __ 6.8 Other encephalopathy specify ______________ENCOS OENP OENOM/OENOD/OENOY OENSC OENRM/OENRD/OENRY (30 char) i.e. metabolic, anoxic, uremic 6.8.1 Specify code for worst stage _____ ENCOC (see codes on opposite page) 6.8.2 Onset date for worst stage ____/____/____ OENSM/OENSD/OENSY MM DD YY 7. PSYCHIATRIC (medically diagnosed conditions) ALCOH __ 7.1 Alcoholism ALCP ALCOM/ALCOD/ALCOY ALCSC ALCRM/ALCRD/ALCRY DRUGA __ 7.2 Drug abuse DRUP DRUOM/DRUOD/DRUOY DRUSC DRURM/DRURD/DRURY DEPR __ 7.3 Depression DEPP DEPOM/DEPOD/DEPOY DEPSC DEPRM/DEPRD/DEPRY PSYCO __ 7.4 Other psychiatric conditions PSOP PSOOM/PSOOD/PSOOY PSOSC PSORM/PSORD/PSORY (excluding cyclosporine or tacrolimus neurotoxicity) VII. MAJOR EVENTS/CONDITIONS since last evaluation (continued): Cont. from |IF NEW, date |Outcome/ |IF RESOLVED, prev. eval |of first onset |current status |date of (check |this eval period |(see codes on |resolution if yes) |(MM/DD/YY) |opposite page) |(MM/DD/YY) ___________________________(YN)______________________________(STCODE)__________________ 8. METABOLIC, TOXIC, OTHER HCHOL __ 8.1 Hypercholesterolemia HCHP HCHOM/HCHOD/HCHOY HCHSC HCHRM/HCHRD/HCHRY HTRIG __ 8.2 Hypertriglyceridemia HTRP HTROM/HTROD/HTROY HTRSC HTRRM/HTRRD/HTRRY (triglycerides > 200 mg/dl) HKAL __ 8.3 Hyperkalemia (treated) HKAP HKAOM/HKAOD/HKAOY HKASC HKARM/HKARD/HKARY CANEM __ 8.4 Chronic anemia ANEP ANEOM/ANEOD/ANEOY ANESC ANERM/ANERD/ANERY (HGB < 10 mg/dl) LEUKO __ 8.5 Leukopenia LEUP LEUOM/LEUOD/LEUOY LEUSC LEURM/LEURD/LEURY (WBC?s < 2,000/mm3) TCPEN __ 8.6 Thrombocytopenia TCPP TCPOM/TCPOD/TCPOY TCPSC TCPRM/TCPRD/TCPRY (platelets < 80,000/mm3) AVNEC __ 8.7 Avascular necrosis (any joint) ___________________________ AVNS specify site (30 char) AVNP AVNOM/AVNOD/AVNOY AVNSC AVNRM/AVNRD/AVNRY HIPAR __ 8.8 Hip arthroplasty, excluding AVN ___________________________ HIPS specify reason (30 char) HIPP HIPOM/HIPOD/HIPOY HIPSC HIPRM/HIPRD/HIPRY KNEAR __ 8.9 Knee arthroplasty, excluding AVN ___________________________ KNES specify reason (30 char) KNEP KNEOM/KNEOD/KNEOY KNESC KNERM/KNERD/KNERY OFRAC __ 8.10 Fractures/osteoporosis FOSP FOSOM/FOSOD/FOSOY FOSSC FOSRM/FOSRD/FOSRY GOUT __ 8.11 Gout (any gouty arthritis attacks) GOUP GOUOM/GOUOD/GOUOY GOUSC GOURM/GOURD/GOURY POUCH __ 8.12 Pouchitis POUP POUOM/POUOD/POUOY POUsc POURM/POURD/POURY VIII. Any TREATED INFECTIONS since last evaluation? Yes___ No ___ INF (YN) Use separate line for each site/organism pair. Infections that occurred more than once should be listed separately (one per line). Infections involving more than one site or more than one organism should be listed separately (one per line). Use codes on opposite page and enter names as well. Site Site name Organism Organism name Cont. from IF NEW, date of Code (30 char) code (30 char) prev. eval. positive culture (check (MM/DD/YY) if yes) (SITE) (INFO) (YN) 1. IS1 ISN1 IO1 ION1 IP1 I1M/I1D/I1Y 2. IS2 ISN2 IO2 ION2 IP2 I2M/I2D/I2Y 3. IS3 ISN3 IO3 ION3 IP3 I3M/I3D/I3Y 4. IS4 ISN4 IO4 ION4 IP4 I4M/I4D/I4Y 5. IS5 ISN5 IO5 ION5 IP5 I5M/I5D/I5Y 6. IS6 ISN6 IO6 ION6 IP6 I6M/I6D/I6Y 7. IS7 ISN7 IO7 ION7 IP7 I7M/I7D/I7Y 8. IS8 ISN8 IO8 ION8 IP8 I8M/I8D/I8Y 9. IS9 ISN9 IO9 ION9 IP9 I9M/I9D/I9Y 10. IS10 ISN10 IO10 ION10 IP10 I10M/I10D/I10Y 11. ____ ____________ ___ ___________________ ____ ___/___/___ 12. ____ ____________ ___ ___________________ ____ ___/___/___ 13. ____ ____________ ___ ___________________ ____ ___/___/___ 14. ____ ____________ ___ ___________________ ____ ___/___/___ 15. ____ ____________ ___ ___________________ ____ ___/___/___ 16. ____ ____________ ___ ___________________ ____ ___/___/___ 17 ____ ____________ ___ ___________________ ____ ___/___/___ 18 ____ ____________ ___ ___________________ ____ ___/___/___ 19. ____ ____________ ___ ___________________ ____ ___/___/___ 20. ____ ____________ ___ ___________________ ____ ___/___/___ 21. ____ ____________ ___ ___________________ ____ ___/___/___ 22. ____ ____________ ___ ___________________ ____ ___/___/___ 23. ____ ____________ ___ ___________________ ____ ___/___/___ 24. IS24 ISN24 IO24 ION24 IP24 I24M/I24D/I24Y IMORE _____ Check here if additional infection(s), and document in COMMENTS section. Use the keywords MORE INF to precede the comments. IX. COMMENTS: Yes ___ No ___ COMM (YN) IF YES COMM COM1 COM2 COM3 COM4 COM5 COM6 COM7 COM8 COM9 COM10 DATA COLLECTOR ID_______ DCID DATA COLLECTION DATE ___/___/____ DCCM/CCD/DCCY MM DD YY