Case Record Form

C.R. No. Department Date of admission Particulars of the patient: Patient ID: Address: District/State: Rural/Urban: Presenting complaint:

A.R. No. Unit

Case no. BED No. Date of discharge

Age:

Sex:

H/O Present illness:

H/O past illness:

Previous medication: 1. Antimalarial drug administered with doses: 2. Others:

Family history:

Personal history:

Socioeconomic history: General physical examination: 1. Temperature (axillary) 2. Respiratory rate 3. Pulse rate 4. Icterus 5. Cyanosis 6. Pallor 7. Blood pressure 8. Body weight in Kg: 9. Other: Local examinations: (Abdomen): 1. Liver 2. Spleen 3. Others

Systemic examinations: 1. Respiratory system:

2. Cardiovascular system:

3. Central nervous system: GCS score

4. Skeletal system:

5. Others Investigations:

Sl no. 1 2 Name of the Investigation Hemoglobin Blood for M.P with

Day 1 Date:

Day 3 Date:

Day 7 Date:

Day 14 Date:

Day 28 Date:

parasite count 3 QBC assay for MP with parasite count 4 5 6 ECG findings Random blood sugar others

Diagnosis: TREATMENT: Antimalarials:

Name

of

the Dosage Date

Start

Last dose

antimalarial drug

Time

Date

Time

Other medications:

Fluid chart:

Temperature chart:

Follow up:

Day 14

Day 28

Remarks: