Clinical pre computer proforma for the international computer database for radiation exposure case histories

1. General Data on the Irradiated Patient.- 1.1 Demographic Data.- 1.2 Occupation at the Time of the Accident.- 1.3 History at the Time of the Accident.- 1.4 Institutions Involved in Patient Care and Database Recording.- 1.4.1 Primary Care Institution Keeping the Patient's Medical Records.- 1.4.2 Definitive Care Institution.- 1.4.3 Physician Submitting the Case to the Registry.- 1.4.4 Source of Compilation.- 2. Accident Information and Personal Exposure Conditions.- 2.1 Accident Description.- 2.1.1 Country.- 2.1.2 City.- 2.1.3 Location (Factory etc.) of the Accident.- 2.1.4 Begin and End of the Accident.- 2.1.5 Proprietor of the Radiation Source.- 2.1.6 General Description of the Accident.- 2.1.7 Number of Persons Involved.- 2.1.8 IAEA Nuclear Event Scale.- 2.2 Source of Irradiation.- 2.2.1 Critical Chain Reaction.- 2.2.2 Reactor Accident with Consecutive Emission.- 2.2.3 Nuclear Explosion.- 2.2.4 Sealed Source.- 2.2.5 Unsealed Source.- 2.2.6 X-ray Equipment.- 2.2.7 Accelerators.- 2.2.8 Other Sources than 2.2.1 - 2.2.7.- 2.3 Personal Exposure Conditions.- 2.3.1 Begin and End of Exposure.- 2.3.2 Individual Description of the Accident.- 2.3.3 External Irradiation.- 2.3.4 External Contamination.- 2.3.5 Internal Contamination.- 2.3.6 Evaluation of the Average Total Body Dose.- 2.3.7 Evaluation of Local Doses.- 2.3.8 Evaluation of Doses of Internal Exposure.- 3 Clinical Data After Exposure.- 3.1 Primary Reaction.- 3.1.1 Dyspeptic Symptoms and Enlargement of Parotid Glands.- 3.1.2 Primary Skin Erythema and Hyperaemia of Mucous Membranes.- 3.1.3 General Neurocirculatory Symptoms and Signs.- 3.2 Involvement of the Nervous System and the Eyes.- 3.2.1 Diagnostic Procedures for Central and Peripheral Nervous System.- 3.2.2 Impairment of Central and Peripheral Nervous System.- 3.2.3 Lesions of Eyes.- 3.3 Radiation Induced Lesions of Skin, its Appendices, and Underlying Tissues.- 3.3.1 Diagnostic Procedures.- 3.3.2 Radiation Induced Skin Lesions.- 3.3.3 Disturbances of Nails.- 3.3.4 Epilation.- 3.3.5 Amputation of Extremities.- 3.3.6 Debridement of Necrotic Tissue.- 3.3.7 Reconstructive Surgery due to Dermal Radiation Lesions.- 3.4 Bone Marrow Syndrome and Blood.- 3.4.1 Peripheral Blood Count.- 3.4.2 Peripheral Blood Smear.- 3.4.3 Bone Marrow Examination.- 3.4.4 Cytogenetic Data.- 3.4.5 Biochemical Data.- 3.4.6 Haemostatic Parameters.- 3.4.7 Immunological and Immunohaematological Tests.- 3.4.8 Microbiological Analysis.- 3.4.9 Lesions of Bone Marrow.- 3.5 Radiation Induced Lesions of Gastrointestinal Tract.- 3.5.1 Diagnostic Procedures.- 3.5.2 Faeces Analysis.- 3.5.3 Radiation Mucositis.- 3.5.4 Acute Gastrointestinal Syndrome.- 3.5.5 Stool Characteristics.- 3.6 Organs Especially Sensitive Under Certain Exposure Conditions.- 3.6.1 Lesions of Upper Respiratory Tract and Lung.- 3.6.2 Lesions of the Thyroid Gland.- 3.6.3 Pregnancy.- 3.7 Lesions of Other Organs.- 3.7.1 Lesions of the Kidneys.- 3.7.2 Lesions of the Liver.- 3.7.3 Evaluation of Male Reproductive Function.- 3.7.4 Evaluation of Female Reproductive Function.- 3.7.5 Lesions of Cardio-Vascular System.- 3.7.6 General Physiological Parameters.- 4. Treatment and Drugs.- 4.1 Individual Radiation Protection Measures.- 4.1.1 Application of Personal Radiation Protectants during the Accident.- 4.1.2 Methods (Drugs) of Early Pathogenetical Treatment.- 4.1.3 Decontamination Measures.- 4.1.4 Decorporation Measures.- 4.2 Physical Methods of Treatment.- 4.2.1 Hospitalisation and Protective Environment.- 4.2.2 Locally Reversed Isolation for Bum Treatment.- 4.3 Substituting Therapy by Blood and Blood Products.- 4.3.1 Irradiation of Blood and Blood Products.- 4.3.2 Blood Groups and Alloimmunisation.- 4.3.3 Whole Blood Transfusions.- 4.3.4 Red Blood Cell Transfusions.- 4.3.5 Platelet Transfusions and Thrombocytapheresis.- 4.3.6 White Blood Cell Transfusions.- 4.3.7 Plasma Transfusions and Plasmapheresis.- 4.3.8 Albumin Solution Infusions, Gamma Globulin Substitution and Other Blood Components.- 4.4 Drugs.- 4.5 Haemostimulators.- 4.5.1 Myelopoietic Growth Factors.- 4.5.2 Other Growth Factors.- 4.5.3 Drugs as Leucostimulators.- 4.6 Haemopoietic Stem Cell Transplantation.- 5. Clinical Status at the Time of Reporting.- 5.1 Survival Status.- 5.1.1 General Information on the Survival Status.- 5.1.2 Loss of Follow-Up.- 5.1.3 Death of Patient.- 5.1.4 Causes of Death.- 5.2 Clinical Status.- 5.2.1 Time of Evaluation.- 5.2.2 Radiation Related Persisting Haemopoietic Disorders.- 5.2.3 Other Persisting Haemopoietic Disorders.- 5.2.4 Radiation Related Persisting Lesions of Skin and Underlying Tissue.- 5.2.5 Other Persisting Lesions of Skin and Underlying Tissue.- 5.2.6 Radiation Related Persisting Lesions of Other Organs.- 5.2.7 Additional Persisting Lesions of Other Organs.- 5.3 Functional Status.- 5.3.1 Time of Evaluation.- 5.3.2 Karnofsky Performance Score.- 5.3.3 Rehabilitation.- 6. Skin Burns.- 6.1 Burn Score.- 6.2 Localisation Coding - Total Body, Head, Neck and Upper Trunk.- 6.3 Localisation Coding - Arms, Lower Trunk.- 6.4 Localisation Coding - Lower Trunk, Legs.- 6.5 Skin Burns.- 7. Haematopoietic Stem Cell Transplantation.- 7.1 Source of Stem Cells.- 7.2 Type of Transplantation.- 7.3 Histocompatibility Tests for Allogeneic Transplantation.- 7.3.1 Typing.- 7.3.2 Donor and Recipient Cells Were Tested for Matching.- 7.4 Donor Information.- 7.4.1 Donor's Demographical Data.- 7.4.2 Donor Relationship and Alloimmunisation History.- 7.4.3 Donor had Serological Evidence of Previous Viral Exposure or Infection.- 7.5 Transplant Manoeuvre.- 7.5.1 Conditioning Therapy prior to Stem Cell Therapy.- 7.5.2 Cells Were Manipulated or Concentrated in vitro.- 7.6 Drugs to Prevent Acute Graft-versus-Host Disease (GvHD).- 7.7 In vitro and in vivo Removal of Donor T Cells to Prevent GvHD.- 7.8 Evidence for Haemopoietic Engraftment.- 7.9 Overall Evaluation of Engraftment.- 7.10 Graft-versus-Host Disease.- 7.11 Specific Therapy for GvHD.- 8. Annexes.- 8.1 IAEA International nuclear event scale.- 8.2 Conversion of Non-SI to SI Units.- 8.3 Orders of Magnitude.- 8.4 Karnofsky Scale for Rating Activity Status.- 8.5 References.- 8.6 Normal Values of Laboratory Parameters.- 8.7 Pages for copying.- 8.7.1 Symptoms and Signs.- 8.7.2 Laboratory Values (left & right).- 8.7.3 Normal Values.- 8.7.4 Antibiogramm (left).- 8.7.5 Antibiogramm (right).