Patient: _______________________________________

Age/Sex: ____________________
PROBLEM LIST
PROBLEM STARTED RESOLVED

Clinical Clerk in-Charge : _______________________________________

WVSU Medicine Batch 2020
Patient: _______________________________________
Age/Sex: ___________________
THERAPEUTIC FLOW CHART

DRUG/MEDICATION STARTED DISCONTINUED

Clinical Clerk in-Charge : _______________________________________

WVSU Medicine Batch 2020
Patient: _______________________________________
Age/Sex: ____________________
THERAPEUTIC INDEX
Drug: ___________________________________________________ Drug: ___________________________________________________
I: ______________________________________________________ I: ______________________________________________________
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MOA: MOA:
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CI: _____________________________________________________ CI: _____________________________________________________
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SP: _____________________________________________________ SP: _____________________________________________________
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AR: ____________________________________________________ AR: ____________________________________________________
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DI: _____________________________________________________ DI: _____________________________________________________
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Drug: ___________________________________________________ Drug: ___________________________________________________

I: ______________________________________________________ I: ______________________________________________________
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MOA: MOA:
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CI: _____________________________________________________ CI: _____________________________________________________
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SP: _____________________________________________________ SP: _____________________________________________________
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AR: ____________________________________________________ AR: ____________________________________________________
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DI: _____________________________________________________ DI: _____________________________________________________
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Drug: ___________________________________________________ Drug: ___________________________________________________

I: ______________________________________________________ I: ______________________________________________________
________________________________________________________ ________________________________________________________
MOA: MOA:
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CI: _____________________________________________________ CI: _____________________________________________________
________________________________________________________ ________________________________________________________
________________________________________________________ ________________________________________________________
SP: _____________________________________________________ SP: _____________________________________________________
________________________________________________________ ________________________________________________________
________________________________________________________ ________________________________________________________
AR: ____________________________________________________ AR: ____________________________________________________
________________________________________________________ ________________________________________________________
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DI: _____________________________________________________ DI: _____________________________________________________
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I-Indication, MOA-Mechanism of Action, CI-Contraindication, SP-Special Precaution, AR-Adverse Reaction, DI-Drug Interactions

Clinical Clerk in-Charge : _______________________________________

WVSU Medicine Batch 2020
Patient: _______________________________________
Age/Sex: ___________________
LABORATORY FLOWSHEET
HEMA CHEM
Hemoglobin FBS
Hematocrit BUN
RBC Creatinine
WBC BUN-Crea Ratio
Neutrophils Uric Acid
Seg Cholesterol
Stab Triglycerides
Lymphocytes HDL
Eosinophils LDL
Monocytes Sodium
Basophils Potassium
Platelets Calcium
Protime Magnesium
% Activity Chloride
INR Acid Phos.
APTT Alkaline Phos.
MCH Amylase
MCV Lactose Dehy.
MCHC SGPT
Blood Type SGOT
Tot. Bilirubin
URINALYSIS B1
Color B2
Trans Tot. Protein
pH Albumin
Sp. Gravity Globulin
Sugar A/G
Albumin FECALYSIS
Pus Cells Color
RBC Consistency
Casts Occ. Blood
Crystals Pus Cells
RBCs
Parasites
Epithelial Cells
Mucus Threads

ECG
X-ray
Ultrasound
CT Scan
Other labs

Clinical Clerk in-Charge : _______________________________________

WVSU Medicine Batch 2020
Patient: _______________________________________
Age/Sex: ___________________
Working Diagnosis: ________________________________________________________________________________
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CASE DISCUSSION
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Clinical Clerk in-Charge : _______________________________________

WVSU Medicine Batch 2020