ANNEXURES

PROFORMA

Case No.:

Name:

Age:

Sex: Male/Female

Marital Status: Married/Unmarried

Race: Caste/ Creed

Religion: Hindu/ Muslim/ Christian/ Sikh/ Others

Occupation: Service/ Business/ Farmer/ Others

Area: Rural/Urban

Locality/Address:

Hospital No.:

IRN No.:

MRD No.:
Ward:

Bed No:

Diet: Vegetarian/ Non Vegetarian:

Socio Economic Status:

ANNEXURES

Date of Admission: 1/2/3 (if person):

Operative Intervention (if any):

Duration of Hospital Stay:

Date of Discharge: 1/2/3" (if person)

Chief Complaints and its Duration:

a) Pain

b) Nausea and Vomiting

c) Fever

d) Abdominal Lump

e) Jaundice
a. Pain:

a. Site: Right Hypochondrium/Epigastrium / Umbilicus/Others.

b. Characters: Dull Aching/Griping/Stabbing /colicky /Others

c. Duration:

d. Periodicity: Absent/Present.

e. Severity. Mild /Moderate/Severe.

f. Radiation/Referred / Shifting of pain: Absent/ Present.

g. Relation with food: Specify accordingly

h. Aggravating factor: Fatty food/ Heavy meal/ Empty stomach.

ANNEXURES

i. Relieving Factor: Spontaneous/ Food Medicine.

Nausea and Vomiting:

a Duration:

b Frequency: 1-2/3-5/ more.

e. Amount: Small/ Copious

d. Taste: Bitter/ Sour/ Acidic

e. Relation with food and pan: Immediately after taking food/ afraid of taking Food due to Vomiting.

f. Character of Vomitus: Water/ undigested or semi digested foofd particle facculant.

g. Specific Colour and Smell: Specify

c. Fever:

a. Onset: Insidious/ Sudden

b. Duration: Specify

c. Nature of Fever: High Grade/Low Grade

d. Associated Complaints: Chills/Rigor/ Sweating/Headache/ Others

d. Jaundice:

a. Duration: Specify

b. Onset: Gradual/ Sudden

c) Daily Earning

d) Smoking: Yes No, if Yes number of Ridi Cipete

e) Chewing Tobacco Yes No 1) Intake of alcohol: Yes No

Family History:

a) Similar Illness: Yes/No

b) History of Obesity: Yes/No

c) History of Diabetes, TB: Yes/No

Dietary History:

a) Vegetarian/Non vegetarian:

b) Fatty food intake: Yes No

c) Meat per week: No/ 1-2/>2 times

Socioeconomic History

a) Per Capita Income;

b) Family Members: <5/>5

c) Occupation: Wages Earner/ Farmer/ Business/Others

d) House: Kaccha/ Pakka

e) Sanitary Toilet: Yes No

f)Water Source: Well/ Common supply

ANNEXURES

Contraception History:

a) Not use/ Use: If yes

b) Pills/ Copper T/ Condoms:

c) Duration:

d) Reasons for Discontinuation:

Menstrual and Obesity History:

a) Menarche:

b) No. of Child:

c) Mode of Delivery:

d) Last Child Birth:

Drug History:

a) Any drug intake for longer duration: Yes/ No, if yes specify.

b) History of herbal medication: Yes/No, if yes duration

c) Present Medication: Specify

PHYSICAL EXAMINATION

1. General Examination:

a. Appearance: Looks ill/ Healthy

b. Decubitus: Normal/ Abnormal/ of Choice

c. Built: Asthenic/Thin/Average/Obese

ANNEXURES

d. Nutrition: Poor/ Fare/ Good

e. Pallor: Present/Absent

f. Icterus: Present/ Absent

g. Cyanosis: Present/Absent

h. Dehydration: Absent/ Present

i. Teeth and Gum: Healthy/ Unhealthy

j. Koilonychia: Present/ absent

k. Clubbing: Present/Absent
1. Neck Veins: Engorged/ Not Engorged

m. Neck Glands: Palpable/ Not Palpable

n. Pulse: min/... Rhythm/...Character/....Condition of arterial wall

o. Blood Pressure: ....mm of Hg

p. Odema: Present/ Absent

2. Systematic Examination:

A. Abdominal Examination:

a. Inspection:

Shape: Normal/ Abnormal

Size: Normal/ abnormal

Condition of Skin: Normal/ Abnormal

ANNEXURES

Umbilicus: Normal./Inverted/ everted

Movements with the respiration: Absent/Present

Visible Lump: Present/ Absent

Engorged Veins: Present/ Absent

Visible Peristalsis: Present/ Absent

Visible Pulsation: Present/ Absent

Hernial sites: Normal/ Abnormal

b. Palpation:

Tenderness: Present/ Absent

Local rise of temperature: Present/ Absent Muscle guarding and rigidity: Present/ Absent Deep Tender
Points: Tenderness: Present/Absent Organomegaly: Present/ Absent Palpable Mass: Present/ Absent, in
detail if present.

c. Percussion:

Liver Dullness: Present/ Absent

Shifting Dullness: Present/ Absent

ANNEXURES

Fluid Thrill: Present/ Absent

Percussion over the Swelling if present

d. Auscultation:
Bowel Sounds: Present/ Absent

Any Bruit: Present/ Absent

e. Per Rectal Examination:

1. Inspection:

Skin Condition: Normal/ Abnormal

Any growth per anus: Present/ Absent

II. Palpation:

Tenderness: Present/ Absent

Digital Rectal Examination: Normal/ Abnormal.

B. Respiratory System: Normal/ Abnormal

(mention if any abnormality detected)

C. Cardiovascular System: Normal/ Abnormal,

(mention if any abnormality detected)

D. Central Nervous System: Normal/ Abnormal. (mention if any abnormality detected)

Provisional Diagnosis:
ANNEXURES

Investigations:

A). Routine investigation:

1.Blood:

1) Haemoglobin level

2) Total leukocyte count

3) Differential leukocyte count

4) Prothombin time

5) Random blood suger

6) Serum creatinine

2.Stool: routine examination and stercobilinogen

3 urine: routine examination and bile pigment

B) Special investigation:

Liver function test:

1. Serum bilirubin:
Total

: Conjugated

: Unconjugated

2. Serum Alkaline phosphate level

3. Serum SGOT

4. Serum SGPT

ANNEXT RES

Serum amylase and Serum lipase

C) Radiological investigation:

1) Ultrasonography of abdomen

2) MRCP

Final diagnosis: Final diagnosis of choledocholithiasis was made after all the investigations which was
being confirmed at the time of operation

Management: in the present study only surgical treatment of choledocholithiasis is

considered
Mode of treatment:

1. Open choledocholithotomy followed by

A) T-Tube drainage

B) Primary closure of CBD

2. Billiary enteric anastomosis

A) Choledochoduodenostomy

B) Roux-n-Y choledochojejunostomy

3. Laproscopic choledocholithotomy with primary closure of CBD In the patients with symptoms of
cholangitis, billiary pancreatitis interval surgery is done. Intially conservative treatment is done by using:

Bed rest

ANNEXURES

Tv fluids/electrolytes

Iv antibiotics/ antispasmodics/ analgesics

Nil by mouth

Continous monitoring of bp pulse temprature and frequent abdominal

examinations.
Post operative complications like:

a) Surgical site infection

b) Loer respiratory tract infection

c) Billiary leak

d) Retained stone

e) Haemorraghe

f) Cholangitis

Total hospital stay:

The total hospital stay of the patient from the day of admission till the date of discharge were noted.