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  • Rashad Medical Case Sheet Final

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    Mariam Qais
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    This document contains a medical history form for following up with patients seen by doctors. It includes sections for patient identifying information like name, age, smoking status and allergies as well as past medical, surgical and drug histories. Clinical exam findings are documented including vital signs, physical exam of different body systems, mental status and recent lab/imaging tests. The form concludes with details of any previous related admissions or consultations and the planned follow up based on the assessment.

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    Rashad medical case sheet Final

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    This document contains a medical history form for following up with patients seen by doctors. It includes sections for patient identifying information like name, age, smoking status and allergies as well as past medical, surgical and drug histories. Clinical exam findings are documented including vital signs, physical exam of different body systems, mental status and recent lab/imaging tests. The form concludes with details of any previous related admissions or consultations and the planned follow up based on the assessment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    5 views1 page

    Rashad Medical Case Sheet Final

    Uploaded by

    Mariam Qais
    This document contains a medical history form for following up with patients seen by doctors. It includes sections for patient identifying information like name, age, smoking status and allergies as well as past medical, surgical and drug histories. Clinical exam findings are documented including vital signs, physical exam of different body systems, mental status and recent lab/imaging tests. The form concludes with details of any previous related admissions or consultations and the planned follow up based on the assessment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    ‫ملف املتابعة من قبل أطباء التدرج‬

    Name (Arabic): Date:

    Age Smoking Allergy

    PMHx:

    PSHx:

    Drug Hx:

    PR SpO2 Bp RR GCS

    Pallor/ jaundice: face sclera conjunctiva deformities:

    Chest: Heart:

    Abdomen: Others:

    Neuro - Musculo: tone & power: posture: walk independently?


    Others:

    Mental (put ✔ ) is he oriented to: his age his name year naming things
    nurse name hospital name his address

    Most recent Ix (Date: )

    RBS HBA1c Urea Creatinine Hb

    Lipid Liver Others:

    ECG CXR

    Details of any previous Emergency admissions or consultations:

    Follow up plan (Adding Ix, Tx ... etc)

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