LIFE THREATENING

(LIFE/ORGAN SAVING)

‫اململكة العربية السعودية‬

‫وزارة الصحة‬
‫ التجمع‬/‫املديرية العامة للشئون الصحية‬
‫مجمع إرادة والصحة النفسية‬
‫بالرياض‬

Day Thursday Date 28/1/2021 Time 4pm :

Patient’s name Saleh Ibrahim Al Amar D.O.B: Gender male
Nationality Saudi ID No. 1031593229 Contact No 0542562711
Referring Hospital
Hospital Name: Nerada( alma) Grade Specialty
Referring Doctor Mohamed Mustafa consultant Phone No 0542562711
Clinical information:
Diagnosis Diabetic foot, Depression, severe anemia
Diabetic foot, diabetic retinopathy , depression , developed diabetic infection and
Brief history cellulitis on ceftriaxone 1 mg/bid, , metronidazole 500 mg tads,

Pallor. Easy fatigability , Last hemoglobin 4.6 mg/dl, WBCs 34000,

Brief physical examination plat more than 700000 fully conscious oriented

Vital signs & Lab investigations:

Blood
Temp SPO2 PR Bp RR RGL
gas
CBC Hemoglobin 4.6
ECG normal
U&E Hyponatremia na 124meq/dl coorected from 114meq/dl
Others
Not done
Images reports:
(X-Ray, U/S, CT, MRI)

Medications Received:
Reason for referral:
Lack of specialty, specify: ……………………………….…
 Lack of physician.
 Not available machine, specify: ……………………………
 Others: ………………………………………………………
Patient need ICU General Ward
Gen.Surgery Nero-Surgery Burn Unit Chest Surgery Vascular Surg.
Medical Pediatric Maxillofacial
Ophth. Urology ENT Others
Transport information:
Date and time of transport Date and time of arrival
/ / Time / / Time

‫النموذج األول‬
‫النموذج األول‬