ARAŞTIRMA EKİBİNDE YER ALAN VE YETKİN BİR ARAŞTIRMACININ İMZASI ADI &
SOYADI TARİH
GEREKTİĞİ DURUMLARDA TANIK İMZASI
ADI & SOYADI GÖREVİ TARİH
73 Ek 2 Olgu rapor formu
İzmir ve çevresinde akut menenjit epidemiyolojisi
Menenjit Çalışma Grubu Hastanın adı ve soyadı: Tarih:
Cinsiyeti: Yaşı: Yaşadığı şehir: Meslek:
Ek hastalıklar: protokol no
Şikayetlerinin başlangıç tarihi: Hastaneye başvurduğu tarih: İzlenen klinik:
Ek olarak belirtmek istediğiniz semptomlar:
Şikayetler Var Yok
Ateş Baş ağrısı Bilinç bulanıklığı Uykuya meyil Bulantı-kusma Kulak ağrısı Kulakta akıntı
Fontanel bombeliği(sadece çocuk hastalar için)
Aşı öyküsü
Travma öyküsü
Kraniyal operasyon öyküsü
Geçirilmiş üst solunum yolu enfeksiyonu öyküsü
74 Tetkikler/tarih Lökosit sayısı Nötrofil % Lenfosit % Serum CRP Serum prokalsitonin BOS direkt bakı BOS pandy BOS Gram boyama BOS protein BOS/kan glukozu BOS kültürü
(Üreme varsa etkeni belirtin)
BOS kültürü
(Üreme varsa duyarlılığını belirtin) BOS PZR
Hastane PZR
Kan kültürü
(Üreme varsa etkeni belirtin)
Kan kültürü
(Üreme varsa duyarlılığını belirtin) Kraniyal görüntüleme
Hastaya verilen tedavi
Tedavi süresi
Destek tedavi
Glaskow koma skoru LP öncesi Antibiyotik öyküsü Antibiyotik adı ve dozu Tedavinin kaçıncı saatinde örnekleme yapıldı
Komplikasyon öyküsü
Ateş yanıtı kaçıncı günde sağlandı
Lökositoz kaçıncı günde geriledi CRP normalleşme süresi
75 Kaynaklar
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