SUMMARY FORM

Bed
no..
CR
No
D.O.A.................

A)

BIODATA

Name: __________________________________________________________________________________
Age: __________________ Sex: ____________ Occupation: ___________________________________
Address : ______________________________________________________________________________

B)

HISTORY :

PRESENTING COMPLAINTS: ___________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________

PAST HISTORY: -________________________________________________________________________

FAMILY HISTORY: -______________________________________________________________________
C)

EXAMINATION FINDINGS :

GENERAL PHYSICAL EXAMINATION:Pulse: ________ B.P: ________ Temp: _______ Anemia: _________ Jaundice: _______

Any other Physical examination finding: ____________________________________________________

Systemic Examination: ___________________________________________________

_________________________________________________________________________
_________________________________________________________________________

D) INVESTIGATIONS:
Blood CP/ESR: - HB%___________ TLC __________ Platelets ___________ ESR______________
Sugar ________Urea_________ Urine DR: ________________________________________________
U/S Abdomen: ________________________________________________________________________
____________________________________________________________________________________
Any other Investigation: ________________________________________________________________

E) PROVISIONAL DIAGNOSIS :
F) TREATMENT:
Drugs used: -

____________________________________________

Conservative/Surgery

___________________________________________________________________________

________________________________________________________________________________________
Surgical treatment: - _______________________________________________________________________
Operative findings: - _______________________________________________________________________
________________________________________________________________________________________
Surgeon: _________________________________________________________________________________
Operation performed: _______________________________________________________________________
_________________________________________________________________________________________

G) COMPLICATIONS:- ___________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

H) MEAN HOSPITAL STAYS: -

______________________________________________________

I) REMARKS: _______________________________________________________________

o Death
o Discharge
o LAMA