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Patient’s name: ________________________ Age /Sex: ________ Job: __________

Address: ___________________ Chief complaint: ________________________ Associated symptoms: ________


CBC Values Remarks Possible cause/ Discussion /What was done to the patient Medications Classification & Action
Hgb Pathophysiology
Hct
WBC
Seg
Lym
Eos
Mono
Baso
Plt
RBC
MCV
MCH
MCHC
Crea
BUN
Uric
Na
K
TropI
TropT
CK-MB
SGPT
SGOT
U/A WBC
RBC
Bacteria

Chest Xray Impression CT/Scan or 12LECG Impression


A
B
C
D
Others

Pearls (Discuss the disease) Criteria Impression

Differential Diiagnoses

Final Diagnosis

Prognosis

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