MALARIA CASE REPORT

CASE NO.

DIAGNOSIS

Patient Identification & Demographics

Patient Name: Hospital:

Ward: Bed no:

Address: Occupation:

Gender: Age:

Height: Weight: Other:

Admission No. Bed No. Adm. Date 𝓈 Time Discharge Date 𝓈 Time

PATIENT PRESENTATION

Chief Complaints

History Of Present Illness

Past Medical History

Family History

Social History

Past Surgical History

Menstrual history:

Personal History
 Allergies (Non-drug)

MEDICATION HISTORY

Drug Allergy:
Drug Purpose Duration Status Response

REVIEW OF SYSTEMS:

 General;

 HEENT;

 Respiratory;

 Cardiovascular;

 Gastrointestinal;
  Genitourinary;

 Musculoskeletal;

 Neurological;

PHYSICAL EXAMINATION:

 General:

 Vital Signs:

BP
PR
RR
 Skin: T

 HEENT:
 Cardiovascular:

 Chest:

 Abdomin:

 Respiratory:

 Nervous system:

 Genitourinary:

 Other:
 RESULTS OF RELEVANT LABORATORY TESTS
Chest X-Ray

ECG

U/S

CT-Scan

MRI etc----:
HEMATOLOGICAL TESTS

Tests Normal Ranges Results Date

RBC
Hgb test
ESR
PCV / Hct
MCV
MCH
MCHC
Retic. Count
WBC/ TLC
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
ANC
PLT
PT
APTT
INR
 LFTs

Tests Normal Ranges Results Date

Bilirubin Total
Direct/Conj
ALT/ SGPT
AST/ SGOT
ALP
GGT
Albumin
Globulins
Total serum prot.

RFTs

Tests Normal Ranges Results Date

BUN
Scr
Clcr

ELECTROLYTES

Tests Normal Ranges Results Date

Na
Cl
K
HCO3/CO2
Ca
Mg
PO4
 BS & HbA1c

Tests Normal Ranges Results Date

RBS
FBS
HbA1c

Results of Other Relevant Tests

TREATMENT AT HOSPITAL

Start- Dosage-Form, Brand (Generic), Dose, Route, Stop-

Date Frequency & Duration Date
DISCHARGE MEDICATIONS

Dosage-Form, Brand (Generic), Dose, Route, Advice / Remarks

Frequency & Duration (If any)

DAILY PROGRESS REPORTS (DPRs)

DPR (Date: / / ) DPR (Date: / / )

DPR (Date: / / ) DPR (Date: / / )

DPR (Date: / / ) DPR (Date: / / )

MEDICATIONS

Number of drugs in hospital treatment Chart:

DRUG#1:

DRUG#2:

DRUG#3:

DRUG#4:
DRUG#5:

DRUG#6:

ADRS

COMPLIANCE

PATIENT EDUCATION/COUNSELING&DRUG INFORMATION

DRUG INTERACTIONS