Medical Case Report
| Name | Purpose | Dosage | Frequency | |
|---|---|---|---|---|
| 1 | Vitamins and Supplements | Maintaining health | 1 tablet | Daily |
| 2 | Calcium | Maintaining health | 1 tablet | Daily |
| 3 | Celestamine | For allergy attacks | 1 tablet | As needed |
| Temperature | Blood Pressure | Heart Rate | Respiratory Rate | |
|---|---|---|---|---|
| 1 | 37.0 | 140/90 | 85 | 22 |
| Normal | Abnormal | Remarks | |
|---|---|---|---|
| Sensory | |||
| Cardiovascular | Irregular heart rhythmn | ||
| Respiratory | Hard to breath at times | ||
| Digestive | |||
| Skin/Integumentary | Edema on right foot | ||
| Bone | |||
| Spinal Cord | |||
| Neurological | |||
| Joints |
| None | Yes | I'm not sure | |
|---|---|---|---|
| Eye problems | |||
| Seizures | |||
| Epilepsy | |||
| Hearing problems | |||
| Diabetes | |||
| Cardiovascular disease | |||
| History of Stroke | |||
| Respiratory problems | |||
| Kidney problems | |||
| Stomach ad liver problems | |||
| Pancreatic problems | |||
| Anxiety and depression | |||
| Other mental health issues | |||
| Sleep disorders | |||
| Neck or back problems |
| Procedure Name | Purpose | Result | |
|---|---|---|---|
| 1 | Chest X-Ray | Check lungs | Normal |
| 2 | Urinalysis | Check urinary tract | Normal |
| 3 | Fecalysis | Check for infection | Normal |
| 4 | Kidney Test | Check functionality | Normal |
| 5 | Ultrasound | Check position | Enlarge |
| 6 | |||
| 7 | |||
| 8 |
Medical Case Report is a research document that is created by the health care team that deals with a specific disease that includes the symptoms, the diagnosis, medical history, patient details, and the treatment. This document is very important for the health care industry because it will be used to further strengthen their medical knowledge and use as proof or evidence about the medical care they will provide to their patients.
This Medical Case Report shows the patient information, the chief complaint, current medical history, medication history, family history, physical examination, review of body systems, vital signs, current medical condition, diagnostic examinations, and treatment. This PDF template is utilizing the Input Table in order to display the data in a table format which makes it easier to read, compare, and understand. This PDF template also displays the name of the author of the document which is usually the assigned physician of the patient being described in the report.
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These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.