You are on page 1of 6

Department of General Surgery

Medical College & Hospital, Kolkata


88,College Street, Kolkata 73
Name : .

Age : ..yr

Sex : M / F

Regn no.:

Unit : .. Ward : DHB Up / DHB Down / Green 5th / CB Top Bed no Shifted to : .
Chief complaints :

Duration

1. ..

2. ..

3. ..

4. ..

History of present illness :

Past history : Major illness -


Operations / Injury - ..
Blood group :

Allergies :

Diabetic ( On Insulin / OHA ) / HTN / Br Asthma /


Co-morbidities :
1

Personal History : Married / Single Smoker / Non smoker / Chews tobacco / Alcoholic / .

Menstrual history : LMP -

..

Concurrent medications : ..
General Survey

Alert & Cooperative / Drowsy / Disoriented / Unresponsive / GCS

Anaemia : Y / N

Cyanosis : Y / N

Jaundice : Y / N

Oedema : Y / N

Pulse : .. / min reg / normal vol / B. P. : / .. mm Hg

E M V
Clubbing : Y / N
Temp : normal / .F

Resp : / min Neck veins : normal / engorged

Cervical L N :

Build : Small / medium / large

Others : .

Nutrition : Average / Poor / Emaciated

Examination of abdomen
Scaphoid / Normal / Full / distended
Prominent veins : Y / N

Umbilicus : Central/ Everted / Inverted / Flush Scar marks :

Moving with resprn : Y / N

Feel : Soft / Rigid/ Guarding / Tender / Rebound

Liver : Not enlarged / Enlarged .. fingers /

..
Spleen : Not palpable / . R kidney : Not palpable / ..
L kidney : Not palpable / .. Ascites : Absent / Present
Lump(s) :
.
Lymph nodes : Not enlarged / .
Other findings : ..
Digital Rectal exam : Normal /

Head & Neck examination


Eyes : Normal / Eye signs
( .. )
Pupils : Normal reaction / ..
Parotid region : Unremarkable /
Thyroid gland : Not enlarged /
Other lumps : ..
Cervical L N : Not enlarged / Enlarged ( Group / Levels .. )
Oral cavity : Unremarkable /
Chest & CVS Respiration : / min comfortable / dyspneic / exertional dyspnoea / Gasping / .....
B/L air entry present / .. Creps / Ronchi . Wheeze / Stridor
S1 , S2 normal / .. Murmurs : none / ..
Chest wall : normal / .
Breast & axilla
Unremarkable / ..
( mark out any lumps in adjoining sketch & label findings )

..
Groin & Genitalia
Hernial orifices : normal, empty / ..
Scrotum & testis : normal / .
Penis : normal /
Nervous system
Skull

: normal / .

Spine

: normal / .

R upper limb : normal / .


L upper limb : normal / .
R lower limb : normal / .
L lower limb : normal / .
Other findings :
.
Provisional Clinical Diagnosis :

Differential diagnoses : .
3

Radiology : X-rays .
USG...
Endoscopy / ERCP : ..
CT / MRI / etc :
FNAC / Biopsy : .
Hb : TLC : . N L M E B

ESR : ..

Platelets : Sugar F:.. PP: ..

Urea : Creat : Na : .. K : . Cl : . Ca : Bilirubin : Conj Unconj .. Albumin


Alk phos : . SGOT : .. SGPT: . P Time : sec ( Control -

sec ) INR

Urine / Stool / Culture / Others :


Hb : TLC : . N L M E B

ESR : ..

Platelets : Sugar F:.. PP: ..

Urea : Creat : Na : .. K : . Cl : . Ca : Bilirubin : Conj Unconj .. Albumin


Alk phos : . SGOT : .. SGPT: . P Time : sec ( Control -

sec ) INR

Operative Note
Surgeons : 1. ..
OT : CB Up /Top/ Green

2. 3.

Date : .. Time :

Position : Supine/ Lithotomy/

Incision: Upper / Mid / Lower midline / Paramedian/ . . Subcostal / Gridiron /


Operative findings :
Operative steps :

Drains : .. Count crosschecked by Dr with Staff nurse ...


Closure : .Skin : Ethilon / Silk / Staples

( Full Signature of Post graduate Resident / RMO/ MO )

Anaesthesia note
Anaesthesiologists: 1. 2. Anaes : GA / Spinal / LA / .
ASA grade : Pre-op assessment : ...
Pre-medications : .. Anaesthetic drugs used :
.
Blood transfused : units I V Fluids infused :
Notes : ...
..
..
4

..

( Full Signature of Post graduate Resident / RMO/ MO )

Post operative directions : as given in Treatment sheet


Ward notes
( on the day of operation )
Consciousness : Drowsy / Alert / Pulse : /min BP : /mm Hg Resp : / min
Temp : .. F Urine : .. ml in hrs

RT aspirate : .ml in hrs Soakage : ..

Abdomen : .. Drain : blood / serosanguinous/ pus/ bilious ml


Chest : .
Date : Time : .am/pm

Seen by : Dr ( signature )

Daily ward notes


Complains of : . Alert/ drowsy/..
Temp : Pulse : / min

BP : /mm Hg Resp : / min

Urine : .. ml

RT aspirate : .ml Soakage : .. Drain : blood / serosanguinous/ pus/ bilious ml


Chest : Abdomen :
...
Date : Time : .am/pm

Seen by : Dr

( signature )

Complains of : . Alert/ drowsy/..


Temp : Pulse : / min

BP : /mm Hg Resp : / min

Urine : .. ml

RT aspirate : .ml Soakage : .. Drain : blood / serosanguinous/ pus/ bilious ml


Chest : Abdomen :
...
Date : Time : .am/pm

Seen by : Dr

( signature )

Complains of : . Alert/ drowsy/..


Temp : Pulse : / min

BP : /mm Hg Resp : / min

Urine : .. ml

RT aspirate : .ml Soakage : .. Drain : blood / serosanguinous/ pus/ bilious ml


Chest : Abdomen :
...
Date : Time : .am/pm

Seen by : Dr

( signature )

Complains of : . Alert/ drowsy/..


Temp : Pulse : / min

BP : /mm Hg Resp : / min

Urine : .. ml

RT aspirate : .ml Soakage : .. Drain : blood / serosanguinous/ pus/ bilious ml


Chest : Abdomen :
...
Date : Time : .am/pm

Seen by : Dr

( signature )

Complains of : . Alert/ drowsy/..


Temp : Pulse : / min

BP : /mm Hg Resp : / min

Urine : .. ml

RT aspirate : .ml Soakage : .. Drain : blood / serosanguinous/ pus/ bilious ml


Chest : Abdomen :
Date : Time : .am/pm

Seen by : Dr

( signature )