Incision position ndication

surgery r Finishing
diagnosis
foClinical Diagnosis
timeStarting PrOP charge in
e Surgeon
timeAnaesthetist
Operative
findings Patientdiagnosis
Post-op Name
Operative
steps PES
of
the
PrOcesune: Institute
Medical
Research & PESof

Alagatron Sciences
12:30pm (Theatre...sn)
OPERATION
:A- NOTES
wh Rattt
Cout
qeduuten fuuplsut T Name
potord nedeuten wud
Tuoo, Sop Age UHID
uder
Neile No....
.
k-wiue Sphol pOten Gender
ceuder Joy énsa :M/F
oud
Aeies wiy few
Stehy Anaesthesia Floor
Type ofNurse Nurse
Scrub Assistant
Assistant
2nd Surgical
1st Scrub
List
p
oues ppy tion. naestwa Conneted Ward:..0
(-aam forte feutu
ttea pafted No.....
..IP
eetillt
aden Emerg.:
Elec. /
Cau reutn L ..Date
Time &
ge ae toete Ratnar :Or:kiran:O PESIMSR/MRF/025/DEC14

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Post-op treatment : ta Selekd Sre (3 Canmula Caneal

Adv
don

ordesy
VOE
Frozen section histology No. :

Report :
O4- y

altnot Ry UEOMol wl

Unit of blood / products transfused:

aub slraten

moutor vitoy
Samples for laboratory examination:

114586

APM¢100OtO
iOrpacdics kiron:
i e s ,DeSimSF

UEMSRKuppam
nSignature (surgeon)
Kuppam - 517425, Chittoor Dist., A.P
 PESIMSRIMRF/003/DEC14

PES Institute of Name:

Medical Sciences UHID No. . . . . . .IP No......Z
& Research
PÈS Age .....
Gender:MIF Ward/Unit :.....
CLINICAL HISTORY / INITIAL ASSESSMENT (IP)
History obtained from:PatientRelative Others

1. COMPLAINTS AND DURATION:

c<o pan o

2. HISTORY OF PRESENT ILLNES:

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hed neiden ts ton 2| o|22 pata
Þppatety Aormal to doys bak folouwuy
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pes fr unts mahaget
3. HISTORY OF PAST ILLNES:
3.1 Diabetes No Yes Details:

3.2 Hypertension No Yes 0 Details:

3.3 Heart disease No es Details:

NoYes Details:
3.4 Stroke
3.5 Cancer NoYes Details:

Tuberculosis NoYes Details:

3.6
3.7 Asthma NoYes Details:

3.8 Transfusion of Blood

or Blood Products NoT Yes Details:

3.9 Past Surgery NoT Yes Details:

3.10 Other:
Page 1 of 4
 4. PERSONAL HISTORY:
4.1 Marital Status: Single Married Separated 4.2 Occupation:
4.3 Diet: Veg Non-Veg 4.4 Appetite : Normal Increased:

4.5 Bowels: Regular Irregular Constipation

4.6 Medication Allergies No Yes J Details:
4.67 Other Allergies No G Yes Details:
4.8 Habits/ Addictions:

a) Alcohol - Teetotaler Occasional Regular Details:

b)Tobacco - Snuff Chewable Smoking Pack years:

c) Drug abuse NoYes Details:

d) Betel Leaf (Paan) No Yes Details:

5. FAMILY HISTORY:
5.1 Diabetes No Yes Details:
5.2 Hypertension Not Yes Details:
5.3 Heart disease No Yes Details:
5.4 Stroke No Yes Details:

5.5 Cancer No Yes Details:

5.6 Tuberculosis No Yes Details:
5.7 Asthma No Yes Details:
5.8 Hereditary Disease:
5.9 Psychiatric illness:,
5.10 Any other:

6. TREATMENT HISTORY & CURRENT MEDICATIONS:

Page
2
7 REVIEW OF SYSTEMS (Please circle as appropriate)

(a) Fever

(b) Weight changes -None / Loss / Gain Kas over .......t

Night Sweats
d) Respiratory -cough, dysponea, wheeze
e) Cardiovascular - palpitation, chest pain, dyspnoea, edema, syhcope
f Gastrointestinal-abdominal pain, diarrhoea, constipation
Vomitings, jaundice, bleeding P/R, hematemesis
1
Neurological -weakness, numbness, headache, fits, altered sensorium
h) Others:

YSICAL EXAMINATION: Appearance : Comfortable Anxious Distressed

Seneral Examination: Pulse tO/mm BP:lIGmnig. RR lC imin Temp-Q2 (F). Spo2: 4z_%
Build. Nutritions Statusna. deelho.
L . . BMI

allorJaundice Cyanosis Edemay Lymphadenopathy Z

Conscious level: Alert &Oriented Confused Drowsy Unconscious Glasgow Coma Scale: S 15

PAIN: No Yes If yes, indicate score from scale: /10

PAIN ASSESSMENT SCALE

1 2 3 4 5 6 7 10
No Just Mild nnoying
Uncomfortable Annoyl Moderate Just Strong Severe Horrible Worst
pain noticeable paln pain pain pain beareble pain palr
pain pain pain
paln

Ocation Character: Sharp / Dull/Aching / Burning /Stabbing

Duration: Acute (<6Weeks Chronic (>6Weeks ) D
Accentuating &relieving factors:
9eaed by
CLINICAL EXAMINATION SYSTEM

-Mo Erenal
--Atud rlanaly roteted but lo taot
boden fet not touhy he
Couel
Page 3 of 4
 -Dbnomol' mobtD
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) Satie ed
INVESTIGATIONS DONE PRIOR TOADMISSION INVESTIGATION ORDEREn

Cafes RET
LET

B4T
RBS
2DEUH
131

DIAGNOsIs
PIGtT NEeKo| EEMOR FRACTU RE

CARE PLAN

-preopth
Sraluaton
udea &luti be
-lpot op achabilitot
-)
Sluçhouttoni 3 kay
Dr.E00JTRA
Date & Time Jr
APMC10680,PGcum
DeptofOrihtpaedics
PESIMS,Káppan DrtiupacüiCS,
Desinsr

Print Name: Dr.

Signature:
Kuppam -517425, Chittoor Dist., A.P