Project 1 Case Study Report Form

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:__________________________
Chest Xray: ______________________
OPS/NPS RT-PCR swab: ___________
Hepatitis Profile: __________________
Medications

Inotropics:
Norrepinephrine: ____________________________________
Dopamine: _________________________________________
Dobutamine: _______________________________________

Antibiotics:
________________________________________________