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Appendix 1:

A. Administration

MEDICAL RECORD RESEARCH

Medical record code: ……………………………………………

1. Full name: ………………………………………………………………2. Age: …….

3. Gender: 1. Male [ ] 2. Female [ ]

4. Address: ………………………………………………….………………………………………………….

5. Phone: …………………………………………………./ ………………………………………………….

6. Date and time of admission: ……/………/………… 7. Date and time of discharge: ………/………/………

B. Risk factors

1. Smoking: 1. Yes [ ] 2. No [ ]

If yes: a. Number of cigarettes/day: ……..b. Number of years smoking: ………c. Quit (number of years): ….

…

2. High blood pressure:

If any:

1. Yes [ ] 2. No [ ]

a. Number of years since discovery: ………b. Highest blood pressure: ………../

………..

c. Regular treatment:

d. Treatment drugs:

1. Yes [ ] 2. No [ ]

d1. ACE inhibitor / AT1 blocker( ) d2. Calcium channel blocker ( )

d3. Beta Blockers

)

( ) d4. Diuretic (

3. Coronary artery disease: 1. Yes [ ] 2. No [ ] If yes:

a. Number of years of discovery: ……… b. Coronary CT scan: [

]

c. Intervention time ………years

d. Regular treatment: 1. Yes

e. Treatment drugs:

[ ] 2. No [ ]

e1. Aspirin / Clopidogrel ( ) e2. Nitrate ( )

e3. ACE inhibitors / AT1 blockers( ) e4. Beta blockers (

)

4. Lipid disorders: 1. Yes [ ] 2. No [ ]

If yes: a. Number of years discovered: ………

b. Regular treatment: 1. Yes

[ ] 2. No [ ]

c. Treatment drugs:

5. Heart valve disease

c1. Statin ( ) c2. Fibrate ( )

1. Yes [ ] 2. No [ ]

If yes: a. Number of years discovered: ………

b. Regular treatment: 1. Yes

[ ] 2. No [ ]

c. Medication: c2. Beta blockers

c1. ACE inhibitor / AT1 blocker ( ) ( ) c3. Diuretic ( )

C. Medical history

1. Reason for hospitalization:

1. Palpitations

2. Chest pain

3. Shortness of breath

4. Other: …………………..

2. Time of onset of symptoms:…………How long……………

3. Common symptoms:

1. Palpitations ( ) 2. Fatigue: ( )

3. Dizziness: ( ) 4. Vertigo: ( )

5. Shortness of breath: ( ) 6. Chest pain: ( )

7. Fainting:

4. Time of atrial fibrillation onset:

( ) 8. Other:…………………………………

1. Morning: ( ) 2. Afternoon:

5. Atrial fibrillation occurs when:

( ) 3. Evening:

( ) 4. Night:( )

1. When resting:

6. Time of atrial fibrillation:

( ) 2. When exerting: ( )

1. < 30 minutes:[ ] 2. 3060 minutes [ ]

3. > 60min: [ ] 4. >24h: [ ]

7. Number of attacks:……… /day or number of attacks:……… /month

8. End of attack:

1. Self-healing:

[ ] 2. Medicine:

[ ] 3. Electric shock:[ ]

9. Treatment drugs:

1. Amiodarone ( )2. Group IA (Procainamide) ( )

3. Group IC ( ) 4. Group II ( )

10. Associated diseases 1. Hypertension ( ) 2. Coronary artery disease ( )

3. Heart valve disease

11. Patient history:

( ) 4. Other diseases ( )

1. Smoking ( ) ( )

2. Quit smoking

( ) 3. Alcohol abuse

D. Clinical examination

1. Height: ……………. (m) 2. Weight:……………. (kg)

3. Heart rate: 1. Regular: [ ] 2. Arrhythmia: [ ]

4. Frequency: ………ck/min 5. TT murmur: [ ] 6. TT murmur: [ ]

7. NYHA class:…………8. Blood pressure: ………./ ………. mmHg 9. Respiratory rate:………… bpm

10. Lungs with rales:[ ]

11. RRPN decrease[ ]

12. RRPN increases [ ]

13. Score: CCS – SAF symptom Score:

14. Score: CHA2DS2 – VASc Score:

…………….

15. Score: HAS – BLED Score:

…………….

E. Paraclinical

1. Basic coagulation:

Code

Parameter	Before CT (a)	6 hours after CT (b)	24 hours after CT (c)
1	Prothrombin Ratio:
2	INR:
3	Fibrillnogen:
4	ACTT/certificate

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2. Blood formula:

Code

Parameter	Before CT (a)	6 hours after CT (b)	24 hours after CT (c)
1	Red blood cells:
2	Hemoglobin:
3	Hematocrit:
4	White blood cells:
5	Platelets:

3. Blood biochemistry test:

Code

Parameter	Before CT (a)	6 hours after CT (b)	24 hours after CT (c)
1	Urea:
2	Creatinine:
3	Glucose:
4	Uric acid:
5	TP Cholesterol:
6	Triglycerides:

Study on cardiac electrophysiological characteristics and treatment results of paroxysmal atrial fibrillation with radiofrequency energy - 26

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