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wikitox:snake_form

CLINICAL RECORD FORM FOR SNAKE BITE

CLINICAL REPORT FORM………………………………………………… Code:…………………………………..……………………………………….
Date:…………………………..Time:…………………………..………………………………………………………………….…………………………….
Calling doctor……………………………………….Hospital Place……………………………………….Phone:…………………………………………
Patient Name………………………………………………………………….Contact Number ……………………………………………………………….
DOB:……………………………………………Age:………………………………………Sex: M / FUR no.…………………………………………….
Animal ID……….Snake……….spider……….marine……….other……….unsure………..not seen………..……………………………………….
Date of Bite………………………………Time of Bite:…………………………..Location at time of bite:……………………………………………..
Body Part Bitten…………………………………………..No of Bites…………..First Aid & Timing……………………………………………………
SYMPTOMS: ………………………………………………………………………………………………………………………………………………………..
SIGNS: ……………………………………………………………………………………………………………………………………………………………….
LAB: …………………………….……………………………..SVDK:Not done…….neg…….pos…….T………B………M……..D………T……..
TREATMENT: ………………………………………………………………………………………………………………………………………………………
RECOMMENDATIONS: ………………………………………………………………………………………………………………………………………….
Date………………….………………….………………….…………………..…………………..………………….…………………..………………….
Time………………….………………….………………….…………………..…………………..………………….…………………..………………….
TREATMENT ……………………………………………………………………………………………………………………………………………………….
Antivenom…………………….………………………………………….…………………….………………………………………….……………………
Other Rx…………………….…………………….……………………..……………………..…………………….…………………….………………….
LAB DATA
PT/INR…………………………………….…………………..………………….…………………..………………….………………….…………………
aPTT………………….………………….………………….…………………..…………………..…………………..…………………..…………………
Fibrinogen………………….…………………………………….…………………………………….…………………………………….…………………
XDP/FDP…………………………………….…………………………………….………………….………………….…………………………………….
Platelets………………….………………….………………….………………….………………….…………………………………….…………………
CK………………….…………………..…………………..……………………………………………………………..………………….………………….
K+ …………………..…………………..…………………..…………………..…………………..…………………..…………………..………………….
Creatinine………………….…………………………………….…………………………………….…………………………………….………………….
Urea……………….………………..………………..…………………………………..………………..……………….………………
WCC………………….…………………..…………………..…………………..…………………..………………….…………………………………….
Lymph………………….…………………..…………………..………………….…………………..…………………..…………………………………..
Hb………………….…………………..……………………………………………………………..…………………..…………………..…………………
LDH………………….………………………………………..……………………………………….…………………………………………………………
AST…………………..…………………..………………………………………..………………….………………….………………….………………….
Other:……………………………………..…………………..…………………..…………………..…………………………………….………………….


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