This document provides guidance for medical interns on case sheet writing and obtaining patient consent. It outlines the necessary components of a case sheet including demographics, history of present illness, past medical history, examination findings, diagnostic testing, treatment plan, and discharge instructions. Tips are provided for taking a patient's history such as introducing oneself, speaking softly, and avoiding hurtful language. The different types of consent are defined including informed consent, written consent, and high risk consent. Obtaining proper consent is emphasized as an important part of hospital practice.

1. Sri Chamundeshwari Medical College
Hospital & Research Institute
Welcomes Interns

2. By
Dr.Roshan Kumar. B.N
Professor HOD – Dept of Orthopedics
Medical Superintendent- SCMCH & RI
Introduction to
Case Sheet Writing
&
Patient Consent

3. Tips Before Taking History…..
Right side of the Patient Left side of the Patient

4. Tip…
Introduce yourself
Talk to the Patient Softly & Politely
Don’t Hurt the Patient With Your Speech Or Touch

5. Pattern for a good Case sheet…
 Demographics
 Presenting History
 Description of History
 Past history
 General Examination
 Systemic examination
 Local examination
 Special examination
 Investigations
 Provisional Diagnosis
 Treatment plan
 Diagnosis
 Treatment modifications
 Course in hospital
 Discharge advice
 Outcome

6. Demographic Data…
 Before interrogating about the complaints of the patient,
 it is a good practice to know the patient first. That means the following headings
should be noted in the history-sheet

7.  NAME.— It is very important to know the patient by name.
The patients like to be asked by name,
 AGE.— Congenital anomalies mostly present since birth,
e.g. cystic hygroma, cleft lip, cleft palate, Acute
osteomyelitis in teenage, and arthritis & degenerative
disorders & carcinomas in the old age.
 SEX.— diseases of the thyroid, cystitis are common in
females while carcinomas of the stomach, lungs, kidneys
are commoner in males.
 Religion:- Carcinoma of penis is hardly seen in Jews and
Muslims , kangri cancers common in kashmiris.
 OCCUPATION.—For example, varicose veins are commonly
seen among bus conductors. While Workers in aniline dye
factories are more prone to urinary bladder. Injury to the
medial semilunar cartilage of the knee is common among
footballers and miners.

8. Chief Complaints.—
In Patient’s own words – No Leading
Questions
Record in chronological order of
occurrence
Eg: 'What brings you here?'.
"How long have you been suffering
(a) Swelling in the neck — 1 year.
(b) Fever (mostly in the evening) — 10 months.
(c) Slight pain in the swelling — 6 months.
(d) Sinus in the neck — 1 month.

9. History of Present Illness.
 The mode of onset of the Symptoms
— whether sudden or gradual,
 The progress of the disease with
evolution of symptoms
 The treatment which the patient might
have received
To know the progress of the disease, the patient
is asked, "What is the next thing that happened?“
–
Can Put Leading Questions

10. Past History
All the diseases suffered by the
patient, previous to the present one,
Should be noted and recorded in a
chronological order.
Diseases like Asthma, Diabetes, TB, HT,
diphtheria, rheumatic fever, bleeding
tendencies, syphilis, gonorrhoea, etc.

11. Drug history / History of allergy
Steroids, Blood thinners, insulin, Antihypertensives,
Diuretics, Hormone replacement therapy, contraceptive pills etc.
Personal history.-
Smoking , Drinking of alcohol (quality and quantity),
Diet (regular or irregular,vegetarian or non-vegetarian, takes spicy food or not etc.)
Marital status
In women, the menstrual history—Regular or Irregular, associated with pain or not, and last date of
menstruation.
The number of pregnancies and miscarriages , whether the deliveries were normal or LSCS

12. Family history
 Many diseases do recur in families.
 Haemophilia, tuberculosis, diabetes, essential hypertension,
peptic ulcer, majority of the cancers particularly the breast
cancer and certain other diseases like fissure-in-ano, piles etc.
run in families.

13. GENERAL SURVEY
Build
Attitude
Clubbing
Pallor
Edema
Nourishment
Cyanosis
Icterus
Lymph nodes
Pulse, Respiration and temperature
B.P
O2 Saturation

14. Systemic Examination
Inspection / palpation/ Percussion/ Auscultation
C.V.S:
Apex beat / Murmers / Arrythmias / Ectopics
R.S
Air entry /Respiratory rate / Ronchi / Rales/ Crepitus
P/A
Softness / Tenderness / guarding / abnormal organs
CNS
Orientation / Sensory / motor / proprioceptive/ reflexes

15. PROVISIONAL DIAGNOSIS
At this stage the clinician you should be able to make
a provisional diagnosis.
You should also keep in mind the differential
diagnosis.
You will now require a few investigations to come to
the proper clinical diagnosis.
If you diagnose a rare disease, you will be rarely correct'.

16. Special Investigations
Blood Investigations
Xray
CT/MRI
ECG
Echo cardiography
Ultrasound

21. Treatment
Progress Notes
Discharge Summary

22. Consent
Very Important Document In a Hospital Practice
Consent is required for :
Examination of a patient / To conduct Investigations
To undertake any procedure on the patient
To Perform Surgery / Delivery
To Record the Patient details for Academic Purpose

23. Types of Consent
 Informed Consent
 Written Consent
 High risk Consent
 Video Consent
 Vicarious Consent
A Consent Should be signed by Patient/ Attendant / Treating Doctor & a
Witness

24. Thank You