CASE RECORD FORM

Topic: LAPAROSCOPIC vs OPEN APPENDICECTOMY: A

COMPARATIVE STUDY
CASE FORM FOR APPENDICITIS:
PARTICULARS OF THE PATIENT:
Name: OP/IP No.
Age:
Sex:
Religion:
Social Status:
Occupation:
Chief Complaint:
History of present illness:
Pain: Site of pain-
Mode of onset of pain-
Change in position of pain or spread of pain-
Type of pain: aggravating or relieving factors-
Vomiting: Character of vomiting-
Frequency of vomiting-
Quantity of vomitus
Bowel habits:
Abdominal Distension:
Urinary Symptoms:
Other history:

History of past illness:

Personal History:

Family History:

Physical Examination

General Survey:
Build and state of nutrition-
Facies-
Signs of dehydration-
Pallor-
Jaundice-
Cyanosis-
Local Examination:
INSPECTION:
Contour of the abdomen-
Skin over the abdomen-
Movements with respiration-
Visible peristalsis-
Hernial orifices-
PALPATION:
Tenderness-
Rebound tenderness-
Hyperaesthesia-
Rovsing’s sign
Cope’s Psoas Test-
Cope’s Obturator Test-
Baldwing’s Test/sign-
Muscle guarding and rigidity-
Mass abdomen-
Other palpation-
PERCUSSION:
Obliteration of liver dullness-

AUSCULTATION:

Bowel Sounds-

DIGITAL EXAMINATION OF THE RECTUM:

EXAMINATION OF EXTERNAL GENITALIA:

OTHER SYSTEMS:
Cardiovascular system-
Respiratory System-
Central nervous system-

PROVISIONAL DIAGNOSIS:

INVESTIGATIONS:
CBP-
CUE-
RBS-
BLOOD UREA-
SERUM CREATININE-
ALVARADO SCORE-
SEROLOGY: HIV HBsAg HCV
ECG-
CHEST X RAY-
ABDOMINAL X RAY ERECT and SUPINE-
USG ABDOMEN

MANAGEMENT-