ComprehensiveClinicalCases
Surgery case proformas
1. Varicose vein.
Patient particulars.
Name
Age
Gender
Address
Education
Occupation
Date of admission
Date of examination.
Chief complaints.
Irregular swelling of the lower limbs.
Constant dull aching pain
Dragging pain in the lower limbs
Ulcer ,eczema,bleeding.
History of present illness.
*Pain
Onset
Duration
Progression
Nature of pain
,Radiation
Aggravating factor
Releving factors
More during night time
Associated night leg cramps.
*varicosities of veins /complications.
H/o swelling at ankle/calf
Itching of the leg
Pigmentation
Eczema
Venous ulcers
*ulceration
Follow ulcer case proforma
*pigmentation and discoluration.
*fever with calf pain
*Distention Of abdomen.
*pregnancy.
*Any condition with raised.intra abdominal pressure.
*smoking
*diagnosed comorbities
*prolonged drug intake.
Past history.
H/o similar complaints in the past.
H/o Hypertension,diabetes mellitus.
H/o chest Pain etc.
,Treatment history
History of allergy to food and any drug.
Menstrual history (in females)
Marital and obstetric history. (In females)
Family history.
H/o hypertension,diabetes,tuberculosis,malignancy.
H/o similar complaints in the family (in case of malignacies)
Personal history.
Vegetarian /non vegetarian
Appatite
Sleep
Bowel and bladder habits
Subactance abuse-smoking,alcohol.
Environmental history
Socio-economic history.
Summary after history.
General physical examination.
Patient is conscious /not ,comparative/not.
Orientation to time ,place ,person.
, Built
Nourishmnet.
Vitals:
Pulse :rate ,rhythm,volume,equality ,character,
condition of the arterial wall,Radio-Radial delay,radio-femoral delay, pse deficit if
any,peripheral pulses.
Blood pressure.:right arm ,supine position.
Respiratory rate,rhythm,type.
Temperature.
Pallor ,
icterus,
Cyanosis
clubbing,
edema,
lymphadenolathy(site ,size,shape,number,consistency,mobility ,matted
,ulceration)
Leukonychia
Height
Weight
BMI.
Head to toe examination
Local examination.
Inspection
Attitude of the limb
Surgery case proformas
1. Varicose vein.
Patient particulars.
Name
Age
Gender
Address
Education
Occupation
Date of admission
Date of examination.
Chief complaints.
Irregular swelling of the lower limbs.
Constant dull aching pain
Dragging pain in the lower limbs
Ulcer ,eczema,bleeding.
History of present illness.
*Pain
Onset
Duration
Progression
Nature of pain
,Radiation
Aggravating factor
Releving factors
More during night time
Associated night leg cramps.
*varicosities of veins /complications.
H/o swelling at ankle/calf
Itching of the leg
Pigmentation
Eczema
Venous ulcers
*ulceration
Follow ulcer case proforma
*pigmentation and discoluration.
*fever with calf pain
*Distention Of abdomen.
*pregnancy.
*Any condition with raised.intra abdominal pressure.
*smoking
*diagnosed comorbities
*prolonged drug intake.
Past history.
H/o similar complaints in the past.
H/o Hypertension,diabetes mellitus.
H/o chest Pain etc.
,Treatment history
History of allergy to food and any drug.
Menstrual history (in females)
Marital and obstetric history. (In females)
Family history.
H/o hypertension,diabetes,tuberculosis,malignancy.
H/o similar complaints in the family (in case of malignacies)
Personal history.
Vegetarian /non vegetarian
Appatite
Sleep
Bowel and bladder habits
Subactance abuse-smoking,alcohol.
Environmental history
Socio-economic history.
Summary after history.
General physical examination.
Patient is conscious /not ,comparative/not.
Orientation to time ,place ,person.
, Built
Nourishmnet.
Vitals:
Pulse :rate ,rhythm,volume,equality ,character,
condition of the arterial wall,Radio-Radial delay,radio-femoral delay, pse deficit if
any,peripheral pulses.
Blood pressure.:right arm ,supine position.
Respiratory rate,rhythm,type.
Temperature.
Pallor ,
icterus,
Cyanosis
clubbing,
edema,
lymphadenolathy(site ,size,shape,number,consistency,mobility ,matted
,ulceration)
Leukonychia
Height
Weight
BMI.
Head to toe examination
Local examination.
Inspection
Attitude of the limb
