SURGICAL CASE RECORD

Wd./Bed ........2......Surgeon
No.
Case
Occupation:
Name:
patient's
Marital Status:

MA.<QL Educatiorr

Admission: .. Date of Operation•

Date of

Discharge: . Address
Date of

Clinical History
ChiefComplaints:
1. po.—ü/) a-bolo-rya-Qw L
2. sin a e

History
ofPresentIllness: (The sequence of events must be
clearly brought out)

CH e4nc-e L
1

PO
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Previous Illness: (If Any) —

Allergy/ Drug/ TreatmentHistory: 1--1o

Social
Economic
Sttus: (s Lo-urou ses

Family Age if Alive. If Dead, Age at Death & its Cause. No

Personal History
Lifestyle: Sedentary / Actfve / Hard Labour

Addiction: Tobacco/ Alcohol / Other Intoxicants C_kADLCC-.-YJ-QJ -b a-LczLgL

2so I

Diet:

txJbTnæA-2./

Any Other Significant / Relevant Past History:

 SURGICAL CASE RECORD
m
Physical Examination

ination:
eneralExa

Appearance:

bujJue
Build:

Status
Nutritional

Hydration:

Pallor

Icterus:

Cyanosis:

Clubbing ...

Oederna:

LymphNodes 00

Vitals:

pulse:

uu-a-.LL
horn
Respiration: 2nr-eU
16 ccc...„
QB. AgrY)./.wo
Temperature•

Any
Findings:
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Systemic Examination

Cardiovascular:

neo

1B..C.A..h-a It')
Respiratory•
ceoUAæo(

Nervous System: a-AL n

GIT (including rectal Examination)•

Local Examination of affected parts (Illustrate by sketch diagrams)

tooLoc-Z

C.A.—Q..O
 SURGICAL CASE
RECORD 13
Clinical Impression
Provisional Diagnosis

favour: Points against:

points in
1.
cosoccb-tu(
2. 2.
3. 3.
Diagnosis: 1.
Differential

3.

4.

5.

InvestigationSuggested: 1.

3.

5.

Reports of Investigation
Investigations
Date Date Date
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FinalAppraisal
Writeyour overall impressionof case at the time of discharge or when you
leave the

A 2e -rex-e-AÄ.-bDl
LEA

c-e.ee-k-c t

RUN-DJ.J

Signature of Student