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DISTRICT MALE HOSPITAL, BUDAUN

RUPEEr
85

OUT PATIENT DEPARTMENT (OPD) TICKET


Date:.. .Department.. .OPD No.
291708
Patient Name. S,D,Wio. .Age,...Sex M/F/Trans.
Adrdress

Chief Complaint(s):
History of present illness:
Past historylfamily history: fur

Medical/Surgical history/Known druf allergy:


1s|12|223

General Physical Examination


Ht:. .cm Wt.......cm Temp... .deg. F Pulse.........nin 'BP.....nmHg RR.....nin.
Pallor- PresenUAbsent leterus-PresentUAbsent Oedema-PresentUAbsent |Cyanosis-PresenUAbsent Dehydration-Mid/Mod/Service
Systemic Examination
CNS: CVS: Resp:

Local Examination

Abdominal Chest: Resp:

Differentialsiagnosis Treatment Plan:

R e y

Investigations:
C3e

L'T

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