Case Record File

On

SURGERY

Published by

Indian Books & Periodical Publishers Block-5/62, Dev Nagar, Pyare Lal Road, Karol Bagh, New Delhi-110005 (India)

Name _________________________________________ Roll No. ____________________ Reg. No ____________

Case Record File

On

SURGERY

Name of the student _________________________________________ Class ______________________ Roll No.____________________ College ____________________

Case Record File On SURGERY

CERTIFICATE
This is to certify that Mr./Miss./Mrs. Is bonafied Student of..college. This book has been presented in the university/council final practical examination held in month Year 200. Date : Place

Roll No..

Signature of student

Signature of the Demonstrator/ Lecturer

Signature of the Professor/ H.O.D

Signature of the Examiner

INSTRUCTION TO STUDENT FOR PRACTICAL WORKS

1. Punctuality in attending I.P.D/O.P.D is to be maintained. 2. Clean apron to be worn before entering the I.P.D/O.P.D. 3. Listen to the instructions given by the teacher for the day. 4. Proceed for Case recording, note your observations, get the records corrected and signed by the tutor. 5. Medicine should be prescribed after due approval of the tutor.

CASE RECORD
Name of the Patient AgeSex. Address. Religion.Occupation Date of RegistrationRegd.No. Final Diagnosis with criteria. 1. CHIEF COMPLAINT OF:

2.HISTORY OF PRESENT ILLNESS (HOPI):

3. PAST HISTORY / ILLNESSES :

4. FAMILY HISTORY / HEREDITARY TRAITS: Maternal Paternal Brother

Sister

5. PERSONAL HISTORY : a). Marital status: b). Occupation: c). Addiction: d). Habit:

e). Sexual system: f). Menstrual : g). Obstetrics:

(6) LOCAL EXAMINATION

INSPECTION

PALPATION

PERCUSSION

AUSCULTATION

(7) GENERAL PHYSICAL EXAMINATION (GPE) Consciousness: Orientation: Memory : Febrile/ Afebrile: Height: Weight: Posture: HAIR Texture Colour EYES Colour: Exophthalmos: Ptosis: Oedema: Conjuctiva: Pupils: Eye Movement: Time / Recent / Place / Past Person

Inflammation / Nystagmus Strabismus

Anaemia /

Jaundice

FACE Facies: Symmetry: Scars & Rashes: MOUTH & PHARYNX Odour: Dental Hygiene: Lips: Tongue:

Colour Eruptions Protusion Appearance

Teeth & Gums: Buccal Mucosa: Pharynx:

Colour Pigmentation Movement of Soft Palate State of Tonsils

NECK Movement: Pain: Veins: Lymph Glands: Thyroid: Carotid Pulse & Bruits: UPPER LIMB Nails: Pulse: Axillae: B.P: Muscle: Power: Tone: Reflexes: Joints: Temperature: THORAX Type of Chest & Symmetry: Breast & Nipple: Respiratory rate: Dilated vessels: Trachea: Apex beat: Respiratory Movement: Vocal Fremitus: Heart Sound: Breath Sound: Vocal Resonance:

Colour Decubitus: Deformity

Wasting Fasciculation

Pain Swelling

ABDOMEN Distension: Symmetry: Scars: Dilated Vessels: Pubic Hair: Hernial Orifices: Palpation: Percussion: Auscultation: LOWER LIMB Balance: Gait: Oedema: Varicosity: Muscle Wasting: Power: Tone: Reflexes: Joint: Peripheral Pulses: Temperature of Feet LABORATORY EXAMINATION :

Movement Swelling

PROVISIONAL DIAGNOSIS :

THERAPEUTICS