Table 6 Medical history and physical examination data about a probable or confirmed case of COVID-19
From: A study to design minimum data set of COVID-19 registry system
Main class | Sub class | Data element |
|---|---|---|
Signs and symptoms at the time of admission | General signs and symptoms | Fever, chills, tiredness, muscle aches, headache, loss of smell or taste, eye congestion, dry mouth, other(s), please specify |
Respiratory signs and symptoms | Dry cough, sneezing, runny nose, dyspnea/tachypnea, constant pain or pressure in chest, nasal congestion, exudative pharyngitis, mucus or phlegm, hemoptysis, other(s), please specify | |
Digestive signs and symptoms | Diarrhea, nausea or vomiting, loss of appetite, abdominal pain, constipation, other(s), please specify | |
Nervous signs and symptoms | Fatigue, decreased consciousness, Glasgow coma scale/score (GCS), functional limb weakness, other(s), please specify | |
Cardiovascular signs and symptoms | Orthopnea, ischemia, angina, arrhythmias, other(s), please specify | |
Others signs and symptoms | Rash on skin, discoloration of fingers or toes, other(s), please specify | |
Review of systems at the time of admission | Vital signs | Pulse rate, respiratory rate, blood pressure, temperature, level of consciousness |
Thorax | Heart murmurs, wheezing, stridor, pleural friction rub, ventricular gallop, atrial gallop, other(s), please specify | |
Abdomen | Tenderness, organomegaly, other(s), please specify | |
Limbs | Edema, weak pulse, other(s), please specify | |
Height and weight | Height, weight, BMI > 30 | |
Other | Others signs and symptoms, please specify, additional comment | |
Underlying conditions and comorbidity | Cardiovascular diseases | Hypertension, heart failure, arrhythmia, ischemic heart disease, other(s), please specify |
Endocrine and metabolic diseases | Type 1 diabetes mellitus, Type 2 diabetes mellitus, unspecified diabetes mellitus If yes, Had the patient’s diabetes be controlled? Metabolic syndrome, other(s), please specify | |
Malignant neoplasms | Morphology, primary site, secondary site If yes, Does the patient receive chemotherapy? If yes, Does the patient receive radiotherapy? Additional comment | |
Respiratory diseases | Chronic obstructive pulmonary disease (COPD), bronchiectasis, interstitial lung disease (ILD), asthma, other(s), please specify | |
Immunodeficiency | HIV/AIDS, congenital immunodeficiency disorders, other(s), please specify | |
The patient is being treated with corticosteroids or immunosuppressant medications If yes, Name of medications used, medications dosage | ||
Chronic neurological or neuromuscular diseases | Cerebral palsy, paraplegia, hemiplegia, multiple sclerosis (MS), old cerebrovascular accident (CVA),other(s), please specify | |
Renal diseases | Chronic kidney disease, end stage renal disease (ESRD), other(s), please specify | |
Liver diseases | Liver failure, liver cirrhosis, hepatitis (A, B, C), other(s), please specify | |
Other important underlying conditions and comorbidity, | Prematurity (infant), mental retardation, other important underlying conditions and comorbidity, please specify | |
Pregnancy, childbirth and the puerperium | Pregnancy, gestational age | |
Childbirth in the last 6 weeks | ||
Menopause | Menopause, menopause age | |
Smoking, drugs abuse and alcohol | Cigarettes, hookahs, alcohol, drug’s abuse, additional comment | |
Medications history | Name of drug, drug dosage, additional comment | |
Previous history of COVID-19 | History of COVID-19 | Had a previous history of COVID-19, illness onset date, disease severity status (mild, moderate and severe), additional comment |
History of COVID-19 vaccination | History of COVID-19 vaccination, number of vaccine doses received, date of administration |