Professional Documents
Culture Documents
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. ..
Allergies :
Personal History : Married / Single Smoker / Non smoker / Chews tobacco / Alcoholic / .
..
Concurrent medications : ..
General Survey
Anaemia : Y / N
Cyanosis : Y / N
Jaundice : Y / N
Oedema : Y / N
E M V
Clubbing : Y / N
Temp : normal / .F
Cervical L N :
Others : .
Examination of abdomen
Scaphoid / Normal / Full / distended
Prominent veins : Y / N
..
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 /
..
Groin & Genitalia
Hernial orifices : normal, empty / ..
Scrotum & testis : normal / .
Penis : normal /
Nervous system
Skull
: normal / .
Spine
: normal / .
Differential diagnoses : .
3
Radiology : X-rays .
USG...
Endoscopy / ERCP : ..
CT / MRI / etc :
FNAC / Biopsy : .
Hb : TLC : . N L M E B
ESR : ..
sec ) INR
ESR : ..
sec ) INR
Operative Note
Surgeons : 1. ..
OT : CB Up /Top/ Green
2. 3.
Date : .. Time :
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
..
Seen by : Dr ( signature )
Urine : .. ml
Seen by : Dr
( signature )
Urine : .. ml
Seen by : Dr
( signature )
Urine : .. ml
Seen by : Dr
( signature )
Urine : .. ml
Seen by : Dr
( signature )
Urine : .. ml
Seen by : Dr
( signature )