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Project 2 Case Study Report Form: Patient Code: Patient Name: Age: Birthday: Hospital Number: Date of Admission
Project 2 Case Study Report Form: Patient Code: Patient Name: Age: Birthday: Hospital Number: Date of Admission
Patient Code:
Patient Name: Age: Hospital Number: Date of Admission:
Birthday: ___/___/___
__/___/___
Height: ____ cm Weight: ____ kg ___ ER days
BMI: ____ kg/m2 ___ Ward days
___ ICU days
Comorbidities: Smoker
Hypertension Yes No
Diabetes Mellitus Pack years:
Heart Disease Alcoholic
Renal Disease Yes No
Others: _______________ How much per week (Amount)
_________
II. Clinical Profile:
III. Outcomes
Vital Signs
Blood Pressure: _____________
Heart rate:__________________
Temperature: _______________
Sensorium
Glasgow Coma Score: _______
Intake:____________________
Output: ___________________
Laboratories
ECG:____________________________
CBC
Hct: _____________________________
Hgb:_____________________________
RBC: ____________________________
WBC:____________________________
Platelet: __________________________
ABG:
_____Compensated
_____Uncompensated
_____Respiratory Acidosis
_____Respiratory Alkalosis
_____Metabolic Acidosis
_____Metabolic Alkalosis
Sodium: ________________________
Potassium:______________________
Creatinine: ______________________
SGPT:__________________________
Medications
Inotropics:
Norrepinephrine: ____________________________________
Dopamine: _________________________________________
Dobutamine: _______________________________________
Antibiotics:
________________________________________________