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Cinical Note Sheet: Prsenting Complaints

This clinical note sheet documents a patient's medical history and physical examination. It includes their presenting complaints, past medical history, physical habits, prior tests and treatments. For pediatrics cases it notes birth and developmental details. The physical exam section documents vital signs and systemic examinations. A provisional diagnosis is given along with a list of investigations ordered.

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Dhananjay Saini
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© © All Rights Reserved
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Download as DOCX, PDF, TXT or read online on Scribd
133 views

Cinical Note Sheet: Prsenting Complaints

This clinical note sheet documents a patient's medical history and physical examination. It includes their presenting complaints, past medical history, physical habits, prior tests and treatments. For pediatrics cases it notes birth and developmental details. The physical exam section documents vital signs and systemic examinations. A provisional diagnosis is given along with a list of investigations ordered.

Uploaded by

Dhananjay Saini
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Patient Name :_____________Age: ______

CINICAL NOTE SHEET Sex : M F


IPD/UHID No:___________ Room No.:____
(To be filled by treating Consultant)
Consultant Name:_____________________
__________________________________________________________________________________
PRSENTING COMPLAINTS :
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Onset : Acute / Sub Acute / Chronic
Course: Stationary / Progressive / Improving
Past History: HTN / DM / IHD / TB / MI / TIA / SD / Drug Allergy / Others
Family History: HTN / DM / IHD / TB / MI / TIA / SD / Drug Allergy / Others
HABIT: Alcohol / Smoking / Tobacco / Drug / Others
INVESTIGATIONS HISTORY / TREATMENT HISTORY:
________________________________________________________________________________
OBSTETRIC / GYNECOLOGY
OBSTETRIC HISTORY G P L Married _______Months/Year Unmarried
MENSTRUAL HISTORY Flow/Cycle Dysmenorrhea / IMB / PCB / Clots
CONTRACEPTIVE HISTORY Barrier Method / OCP / IUD / Implants

PEDIATRICS :-
Birth History Type of Delivery Normal CS PRE TERM
POST TERM
Congenital Defects
Developmental History / milestone history
__________________________________________________________________________________
PHYSICAL EXAMINATION :
I. GENERAL GC: Good / Fair / Low SPO2 RBS

Pulse Pallor Dehydration


BP Ieterus Cyanosis
Temp. Clubbing Oedema
Respiration Lymph Nodes Peripheral Pulse
II. SYSTEMIC EXAMINATION :
Cardiovascular : LOCAL EXAMINATIONS :
Respiratory :
Abdomen :
Musculo-Skeleton System :
CNS :
PV :
PR :
__________________________________________________________________________________
III. PROVISIONAL DIAGNOSIS :
1- ______________________________________________________________________
2- ______________________________________________________________________
3- ______________________________________________________________________
__________________________________________________________________________________

INVESTIGATION ORDERED :
Test name Tick Test name Tick Test name Tick
CBC RBS ECG
ESR Fasting/PPBS X ray
Platlets Counts Urea USG
GBP Creatnine AFB, Gram stain
BT/CT S. NA+, K+ ECHO
PTINR Calcium TMT
Blood Group Alkiline Doppler
Lipid Profile SGOT,SGPT CT: Plain/Contrast
Widal LFT MRI
Typhi Dot KFT EEG
Dengue Profile Urine R/M Others

Sign of Consultant : Date & Time :

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