THROMBOLYSIS DATA

NAME: GENDER:

IC: Age:

DATE THROMBOLYSIS:

REFERRAL FROM/ WALK IN TO CASUALTY:

WAS EMERGENCY CALLED: YES/NO

WAS HOSPITAL CONTACTED BEFORE THE ARRIVAL OF PATIENT: YES/NO

Underlying:

NO UNDERLYING YES/NO
1 Diabetes Mellitus
2 Hypertension
3 Dyslipidemia
4 Coronary heart disease
5 Atrial fibrillation
6 Smoker
7 Alcoholic
8 History of stroke

NIHSS:

No NIHSS RESULT
1 Pre thrombolysis
2 Post thrombolysis 0 hour
2 hours
24 hours
7 days

Complications:

No Complications YES/NO
1 Allergy reaction
2 SICH
3 Hypotension
4 Fatal cardiac event
5 Gum bleeding
6 In patient mortality
If yes, cause of death:

MRS upon discharge: