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Vital Signs

Parameter BP Temp RR PR Normal Range 120/80 mmHg 37.2C 12-18 bpm 60-100 bpm Date D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D1 4

Full Blood Count


Paramet er WBC RBC Hb HCT Plt Reference range 4.5 11.0x109/L 4-4.9 x1011/L 12.0 15.0g/dL 36 44% 150 450x109/L Date 1 2 3 4 5 6 7 8 9 10 11 1 2 13 14 Ref Range HTAA 4.0-10x109/L 4.5- 6.5x1012/L 13-17 g/dL 150-450 x109/L 40-50%

Renal Profile Paramet er BUN sodium potassiu m chloride Creatinin e Creatinin e Clerance Reference range 2.5 -7.5 mmol/L 133-148 mmol/L 3.5-5.1 mmol/L 95-108 mmol/L 44-133 mol/L 105-150 ml/min Date 9 10 Ref Range HTAA 2.8 7.2 136 146 3.5 5.1 98 106 59 104 105 150

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12

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14

where Constant is 1.23 for men and 1.04 for women

Ideal Body Weight (IBW) or Lean Body Weight (LBW) Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet
* 1 ft = 12 inch. 5 ft = 60 inch.

Use Total Body Weight (TBW) if TBW < LBW Use Adjusted Body Weight (ABW) if obese > 125% of LBW Adjusted Body Weight ABW = LBW + 0.4 (actual weight - LBW)

Liver Profile
Paramete r Albumin Total Bilirubin Total protein ALP ALT AST Globulin Direct Bilirubin Indirect Bilirubin Ag ratio * a change is only significant if it is at least 3x more/less than the normal value. Reference range 35-50 g/L <20 umol/L 66-87 g/L 53-141 /L <32 /L Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Ref Range HTAA 35 52 5 21 66 83 g/L < 129 /L 0 45 /L 0 35 U/L 20 35 g/L 0 3.4 mol/L 0 12 mol/L 1 2.2

Cardiac Enzymes Parameter CK LDH AAT Reference Range 24-195 0-248 < 37 Unit u/L u/L Date 1 2 3 4 5 6

Coagulation Profile
Parameter PT APTT INR Reference Range 10-13.5 26-42 < 1.5 Unit Sec Sec Date 1 2 3 4 5 6

Lipid Profile
Parameter T-Chol C-TG C-HDL C-LDL Reference Range <5.7 < 1.7 > 1.7 < 3.9 Unit mmol/L mmol/L mmol/L mmol/L Date 1 2 3 4 5 6 7

Others
Parameter RBS Hb1AC Reference Range < 11.0 4.0-6.0 Unit mmol/L mmol/L Date

Blood Sugar Monitoring Chart


Normal FBS: 3.9-5.5 mmol/L Normal RBS: < 7.8 mmol/L

Date

Time

Measurement (mmol/L)

Date

Time

Measurement (mmol/L)

Date

Time

Measurement (mmol/L)

COMPLIANCE ASSESSMENT (Choose either A or B)


A. i) Patients Report (Morisky Scale) No. 1 2 3 4 QUESTIONS Do you ever forget to take your medications? Are you careless at times about taking your medications? (Do you sometimes miss a dose?) When you feel better, do you sometimes stop taking your medications? Sometimes if you feel worse when you take your medications, do you stop taking them? SCORE * Compliant score indicator: (4) noncompliant; (3) poor; (2) average; (1) satisfactory; (0) compliant YES 1 NO - 0

ii) Other relevant questions (optional) 1. Does the patient take full responsibility for his/her medication administration or is he/she assisted by someone else? 2. Does patient understand reason for taking medication? 3. Does patient ever use someone elses medication? 4. Does patient ever share medication with anyone else? 5. Does patient normally bring along medication with him/her? 6. Does patient worry about side effects of his/her medication?

Yes

No

7. What does patient do if a dose is missed? ________________________________________ __________________________________________________________________________ 8. Under what circumstances and how frequently are doses missed? _____________________ __________________________________________________________________________ 9. How are the medications stored? _______________________________________________ _______________________________________________________________________