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PHIẾU THU THẬP THÔNG TIN

Số bệnh án............

1. Họ và tên...........................................................................tuổi..........................

2. Địa chỉ.............................................................................................................

3. Ngày vào viện...................................................................................................

4. Ngày ra viện .....................................................................................................

5. Tình trạng sinh đẻ (para)...................................................................................

6. Tiền sử phẫu thuật vùng tiểu khung..................................................................

7. Kinh nguyệt............................Chậm kinh..................Không chậm kinh..........

8. Thời gian chậm kinh.......................................................................................

9. Đau đầu .............................Có .................................Khơng ...........................

10. Buồn nơn ........................Có...................................Khơng............................

11. Nơn ................................Có ..................................Khơng............................

12. Đau bụng.............................Có.................................Khơng...........................

13. Ra máu âm đạo...................Có.................................Khơng............................

14. Kích thước tử cung: Bình thường hay to hơn bình thường...........................

15. Phần phụ...................Có khối.....................................Khơng có khối.............

16. Cùng đồ....................Đau...........................................Khơng đau....................

17. Siêu âm kích thước khối chửa:

+ Trước điều trị

+ Sau điều trị

18. Siêu âm dịch cùng đồ:

+ Trước điều trị

+ Sau điều trị



19. Định lượng hCG:

+Trước khi tiêm MTX

+ Khi tiêm MTX

+ Sau khi tiêm MTX 1 tuần

+ Sau khi tiêm MTX 2 tuần

+ Sau khi tiêm MTX 3 tuần

+ Sau khi tiêm MTX 4 tuần

















20. Phương pháp điều trị

1 liều MTX 

2 liều MTX  3 liều MTX 

21. Kết quả điều trị: Thành công 

Thất bại 

22. Số ngày điều trị



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