PMIS/MIS-C SPACT DATABASE
Project Coordinators : Dr. Ashish Goti (9558119292), Dr Zainul Gagan(9879059629), Dr Siddharth Arora(8527375977), Dr Mihir Patel(9099024442)
Patient Name
*
Mobile
*
Patient Age
Y/M
*
Year
Months
Gender
*
Male
Female
N/A
Area of Residence
*
Amroli
Adajan
Althan
Athwagate
Bhatar
Dindoli
Central surat
Ghoddod
Katargam
Limbayat
Mota Varachha
Pal
Parvat Patia
Nanpura
Rander
Udhana
Varachha
Vesu
Variyav
Sarthana
out of surat
Doctor's Name
*
Hospital/Clinic Name
*
H/o Covid19 in recent past?
*
Yes
No
Date Of Admission
/
Day
/
Month
Year
1
Date Of Onset of Symptom
/
Day
/
Month
Year
2
Close Contact with Covid 19 +ve?
*
Yes
No
Days of Fever
Any Comorbidity?
Yes
No
Chief complaints
General Exam
Vitals
RS
CVS
CNS
Per Abdomen
Hematological
Echocardiography
*
Done
Not done
Echo. findings
Attach Echo
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Was Patient Misdiagnosed/alternate diagnosis made?
Yes
No
Diagnosed on basis of
Investigations
HB
TLC
PLT
Polymorph
Lympho
Eosinophil
Monocyte
Basophills
CRP
ESR
D dimer
Pro BNP
S. Ferritin
NT Pro BNP
LDH
Troponin T
IL6
SGPT
s. Creatinine
Biliirubin
CPK
S. Sodium
S. Potassium
S. Chloride
COVID ANTIBODY levels
Evidence of Urinary Protienuria
Yes
No
Total Protein level
Treatment given
Steroid Dose
Final Outcome
Complications
Total Hospital Days stay
Follow up Echo Echocardiography
Comments
Patient Went in Shock?
*
Yes
No
Attach Patients file, investigations, Echo report etc here.
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of
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