|
Patients who replies "No" to any of the above questions will not enter the study | |
|
1. Patients with either II-degree debrided burn wound or donor site | |
|
3. Ages between 18~65 years old | |
|
Doctor's signature |
|
|
Date | yyyy-mm-dd |
|
Patients who replies "Yes" to any of the above questions will not enter the study | |
|
Doctor's signature |
|
|
Date | yyyy-mm-dd |
|
If yes, please describe |
|
|
Other diseases | |
|
If yes, please describe |
|
|
History of allergic disease | |
|
If yes, please describe |
|
|
If yes, please describe |
|
|
Route of Administration |
|
|
Name of Drug |
|
|
Dosage per Day |
|
|
Start Date |
|
|
Systolic pressure (SP) | mmHg |
|
Respiratory rate | 次/分 |
|
Grouping | |
|
Diastolic pressure (DP) | mmHg |
|
End Date |
|
|
Doctor's signature |
|
|
Date | yyyy-mm-dd |
|
Pulse rate | 次/分 |
|
Marital status | |
|
Date of birth | yyyy-mm-dd |
|
Education level |
|
Wound Location |
|
|
Wound Surface Area | cm2 |
|
Signs and Symptoms | |
|
Wound Bed (erythema) | |
|
Wound Bed (exudation) | |
|
Wound Type | |
|
Wound Bed (bleeding) |
|
Uric acid | μmol/L |
|
Creatinine | μmol/L |
|
Urea nitrogen | mmol/L |
|
Serum albumin | g/L |
|
Serum bilirubin | μmol/L |
|
AST | U/L |
|
ALT | U/L |
|
Urine protein | g/L （或定性） |
|
Urine red cell | 个/μL （或定性） |
|
Urine WBC | 个/μL （或定性） |
|
PLT | X10*9/L |
|
Hb | g/L |
|
RBC | X10^12/L |
|
WBC | X10*9/L |
|
Routine Urinalysis | |
|
Routine Blood Test | |
|
Renal Function Test | |
|
Date of test |
|
|
Date of examination | yyyy-mm-dd |
|
Date of test | yyyy-mm-dd |
|
Liver Function Test | |
|
Date of test | yyyy-mm-dd |