Form 190 - Quantitative Liver Function Test Record

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HALT-C Trial
Quantitative Liver Function Test Record –QLFT AS
Form # 190
Version B: 07/06/2001
SECTION A: GENERAL INFORMATION
A1. Affix ID Label Here 
___ ___ - ___ ___ ___ - ___
A2. Patient initials: __ __ __
A3. Visit number: __ __ __
A4. Date form completed: MM / DD / YYYY
__ __ / __ __ / __ __ __ __
A5. Initials of person completing form: __ __ __
SECTION B: PATIENT INFORMATION
B1. Patient weight: __ __ __.__ kg or __ __ __ lbs
B2. Patient height: __ __ __ cm or __ __ in
SECTION C: BASELINE SAMPLES: MEGX, Cholate, Galactose, Caffeine & Antipyrine
C1. Date of test: (MM/DD/YYYY) __ __ / __ __ / __ __ __ __
Procedure
Description
Projected T-Time
Actual 24hr Clock Time
HH:MM
____ ____ : ____ ____
C2.
MEGX
1 x 5ml red top
30-60 min before T=0
C3.
Cholate
1 x 5ml red top
30-60 min before T=0
____ ____ : ____ ____
C4.
Galactose
1 x 5ml gray top
30-60 min before T=0
____ ____ : ____ ____
Caffeine &
C5.
1 x 3ml saliva
30-60 min before T=0
____ ____ : ____ ____
Antipyrine
SECTION D: ADMINISTRATION OF TEST COMPOUNDS
Procedure
Description
Projected
a. Actual
b. Actual 24hr Clock
T-Time
Timer End
End Time (HH:MM)
T-Time
D1. Start timer
T = 0 min
____ ____ : ____ ____
Administer IV
0.5mg/kg 2%
____ ____ : ____ ____
D2.
T = 0 - 2 min
____ ____ min
compound A
Lidocaine
Flush line with
D3.
T = 2 - 3 min
____ ____ min
____ ____ : ____ ____
NS
Administer IV
100mls 30%
D4.
T = 3 - 8 min
____ ____ : ____ ____
____ ____ min
compound B
Galactose
Flush line with
D5.
T = 8 - 9 min
____ ____ : ____ ____
____ ____ min
NS
40mg 4d-Cholate,
Administer oral
300mg Caffeine,
D6.
T = 8-9 min
compounds
500mg Antipyrine in
____ ____ min
____ ____ : ____ ____
juice; rinse
HALT-C Trial
QLFT AS
Form # 190
Version B: 07/06/2001
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