Name of Patient:

Age/Sex:
CC:
WDx:
Date and Time Admitted:

CASE DISCUSSION
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Clinical Clerk-in-Charge
WVSU Medicine 2016

Patient:
Age/Sex:

Clinical Clerk-in-Charge
WVSU Medicine 2016

THERAPEUTIC FLOW CHART

DRUG/MEDICATION

STARTED

DISCONTINUED

Patient:
Age/Sex:

LABORATORY FLOWSHEET
HEMA
Hb

CHEM
FBS
Clinical Clerk-in-Charge
WVSU Medicine 2016

Hct
RBC
WBC
Neut
Seg
Stab
Lymph
Eos
Mono
Baso
Platelets
MCH
MCV
MCHC
Protime
INR
APTT
CT/BT
Blood Type/Rh
URINALYSIS
Color
Trans
pH
Sp. Grav:
Sugar
Albumin
Pus Cells
RBC
Casts
Crystals

BUN
CRE
BCR
UA
CHOL
TAG
HDL
LDL
Na
K
Ca
Cl
ACP
ALF
AMS
LD
SGPT
SGOT
Tot. Bili.
B1
B2
Tot. Prot.
Alb
Glob
A/G

FECALYSIS
Color
Consist.
Occ. Blood
Pus Cells
RBCs
Parasites

Epith Cells
Muc. Threads
X-ray
UTZ
CT Scan

Other Labs:______________________________________________________________
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Patient:
Age/Sex:

PROBLEM LIST
PROBLEM

STARTED

RESOLVED

Clinical Clerk-in-Charge
WVSU Medicine 2016

Patient:
Age/Sex:

THERAPEUTIC INDEX
Drug:____________________________________________________________
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MOA:_____________________________________________________________
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Clinical Clerk-in-Charge
WVSU Medicine 2016

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Clinical Clerk-in-Charge
WVSU Medicine 2016

DI:_______________________________________________________________
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DI:_______________________________________________________________
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MOA:_____________________________________________________________
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CI:_______________________________________________________________
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SP:_______________________________________________________________
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AR:_______________________________________________________________
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DI:_______________________________________________________________
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Clinical Clerk-in-Charge
WVSU Medicine 2016