Daily Follow-up for SEVERE ACUTE RESPIRATORY SYNDROME (SARS) PATIENT

 

Date of Follow-up ___/___/__ (YY/MM/DD)             –              Number of days since admission: ________

 

Diagnosis:

  Suspect Case – Symptomatic (but does not meet case definition of probable case)        

  Probable Case

  Person under Investigation

  Other, specify

 

Medication:

__________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

 

SARS symptoms (not present, improving, same or worse):

·         Cough ____________________________________________________________________________________

 

 

·         Sputum (usually non-productive)_______________________________________________________________

 

·         Shortness of breath (at rest or exertion) __________________________________________________________

 

·         Headache _________________________________________________________________________________

 

·         Myalgias __________________________________________________________________________________

 

·         Nausea/vomiting ___________________________________________________________________________

 

·         Diarrhea _________________________________________________________________________________

 

·         Fatigue ___________________________________________________________________________________

 

·         Other ____________________________________________________________________________________

 

On Ribavirin – Y or N (circle)

Ribavirin associated symptoms

·         Headache _________________________________________________________________________________

 

·         Nausea and/or vomiting ______________________________________________________________________

 

·         Anorexia __________________________________________________________________________________

 

·         Anemia associated symptoms  _________________________________________________________________

 

·         Fatigue ___________________________________________________________________________________

 

·         Rash _____________________________________________________________________________________

 

·         Confusion, insomnia or sleeplessness ___________________________________________________________

 

·         Other ____________________________________________________________________________________

 

Other symptoms:

__________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Physical examination (Do not examine patient unless necessary)

 

Max Temp since day before: _______

 

Lowest O2 sat on R/A since day before: _______ 

 

HR: ________  BP: _______  RR: ________

 

 

 

 

Labs

Hb: ________      WBC: _________              Lymphocyte count*: _________      Platelet count: __________

 

Na: _________    K: _________                      Chloride: ________                    CO3: ________

 

Cr: _________    urea: _________                BS: _________

 

Mg: ________     Ca: _________    Albumin: _________

 

AST*: _______   ALT*: _________              ALP: _________                Bilirubin: _________

 

LDH*: ________                CK*: ________   Lipase*: _________

 

CXR done today – Y or N (circle)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Assessment:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

 

Plan for tomorrow:

 

·         Labs ordered for tomorrow – Y or N (circle)

 

·         CXR needed tomorrow – Y or N (circle)

 

·         ICU to see patient – Y or N (circle)

 

·         Any change in medication – Y or N (circle) – specify _____________________________________________

 

·         Other issues and plans:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________