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- 1. 1 Ayushman Bharat ‘Niramayam’Madhya Pradesh Medical Case Sheet Hospital Name ……….…… ……………. District ……………….….. Ward No. ……..….. Bed No. ………. Name : OPD/IPD No. : Age : DOA : Sex : DOD : Religion : Unique ID Though TMS : ……………... Education : Marital Status: Occupation : Samagra ID No.: Golden Card ID: Postal Address:
- 2. 2 Main Complaints– 1. PresentingComplaint 1…………………. 2…………………. 3………………………….. 1. Associated Complaints (related to main complaints) 1.…………………………. 2…………………..3 …………………………. I. History 1. History of present illness 2. History of past illness 3. Family History 4. Personal History 5. Treatment History 6. Sexual/Social/Occupational etc. II. Examination 1. Physical Examination – Pulse……………, Respiration……………, Temperature…………., Blood Pressure………… Weight/Height…….Built……….Scalp………..Eyes………Nose……Oral Cavity…………………. Tongue……….. Neck Glands……… Nails……….. Edema…...... Lymph Nodes…….…Pallor/ Anemia……………. Cyanosis…….. Jaundice …….. Pigmentations……other…………………….. 2. Systemic Examination - 2.1 Respiratory System- a. Inspection- Respiratory Rate & Rhythm………………………………………………………………………. Shape and symmetry of the chest…………………………………………………………………. Nose ……………………………………………………………………………………………….. Throat ……………………………………………………………………………………………… Cyanosis …………………………………..others ………………………………………………... b. Palpation - Confirmation of respiratory moments …………………………………………………………….. Position of Mediastinum ………………………………..………………………………............... Tenderness ……………………………… others ………………………………………………… c. Percussion - Resonant - normal …………………………………abnormal …………………………………… Cardiac dullness - normal …………………………abnormal …………………………………… Liver dullness - normal …………………………. abnormal …………………………………….
- 3. 3 Dullness in otherfield indicates – Pleural Effusion ……………………………………………….. Lobar Pneumonia ……………………………………………. Hyper resonance indicates - Pneumothorax …………….…………………………………. Emphysema …………………………………………………. d. Auscultation – Breath sounds Vesicular …………………………….…………………………………………….. Bronchovesicular ………………………………………………………………………………….. Bronchial breathing sounds – Tubular……………………………………………………………. Cavernous………………………………………………………….. Amphoric ………………………………………………………….. Added Sounds – Crepitations …………………………………………………………………….. Rhonchi …………………………………………………………………………. Pleural rub ………………………………………………………………………. Others …………………………………………………………………………… 2.2 Cardiovascular System – Pulse rate ……………………., Rhythm ……………………………Volume ……………………… Character ……………………., Blood pressure …………………………………………………....... Sign of CCF – Raised JVP …….Tender hepatomegaly…….. Pedal edema………………………… Others – Clubbing ………………….. Cyanosis…………….. Anemia …………………………….. Inspection – Chest Wall shape……….. Apex beat …………. Other pulsations………………….………………. Palpation – Apex beat location …………… Character …………. Tender areas………………………………… Any other palpation location ………… Character…… Tender areas………………………………. Thrills – Systolic ……………………………. Diastolic …………………………………………… Percussion – Dull note – Location …………………………….., Character …………………………................... Auscultation – Heart sounds 1st - ……………………. 2nd ………………… Splitting…………………………...... Added sounds ……………………………………………………………………………………..... Murmurs – Site ……………………...Timing ……………………… Character …………………..
- 4. 4 Pitch …………………...…………….Grade……………………………………………………... Pericardial rub–Present ……………. Absent …………………………………………………... Others …………………………………………………………………………………………….. 2.3 Gastrointestinal System/Per-abdominal Examination – Oral Cavity – Lips – Fissure ………. ……………Cracks …………………... Discoloration ……….…………… Teeth – Dental caries – Present …………………..…….. Absent ………………………..……….. Tongue – Coating ….. ……….Fasciculation…………… Cracks …………. Wasting …….………. Tonsils – Enlargement ……………………............ Normal …………………………..……………. Per Abdomen - Inspection – Shape - Normal ………………………………. Abnormal ………………………………………..... Movements with respiration ………………………………………………………………………....... Umbilicus- Inverted …….………….. Everted…………………………………………….…………. Hernial orifices – Epigastric ………. Umbilical………………… Inguinal……….……………….. Femoral…………………………….. Incisional ……………………………………………………. Visible blood vessels – Present ………….…..Absent ……………………………………………… Striae – Present …………………..…… Absent ………………… Others ………………………… Palpation - Tenderness …………………………………. rigidity ………………………………………..……. Liver – Size ……… Tender …….. Margin …..….. Consistency…….…………………………... Spleen - size ……… Tender …….. Margin …..….. Consistency…….………………………….. Swelling – Present …………………………… Absent …………………………………………... Rebound tenderness – Present ………………………… Absent ……………………………….. Percussion – Free fluid – Present ………………….……Absent ……………………………….. Dullness grade 1…………….. 2……………... 3………..Present Shifting ……………………… Auscultation–Peristaltic sounds – Present ……………..Absent …………………………………. Rubs - Hepatic…………………………… Splenic ……………………….……….. Others – Per Rectal examination - ……………………………………………………………….… 2.4 Central nervous system – Mental Status – Consciousness – Drowsiness …….…Stupor……. Semi coma……..Coma...……
- 5. 5 Memory – Loss……………………………..….. Normal ……….……………………………….. Orientation of Time and Place –Present …………………………….Absent ……………………. Speech –Dysarthria………………………………….. Dysphasia………………………..…………. General behavior – Normal ……………………..…. Abnormal ……………….…………………. Hallucinations and delusions ……………………………...…………………… Gait – Ataxic gait…………………... Antalgic gait…….……….. Cerebellar gait …….………….. Hemiplegic gait ……………... Spastic gait….……………. Scissor gait...……Others …..... Cranial Nerve Examination – from 1st to 12th cranial nerve finding details………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… Motor system – Nutrition /Muscle bulk……………………………………………………………………………………… Muscle power / strength score 0………. 1 …………..2 ………..3……………4………..5………….…. Muscle tone– Hypotonia ……………….. Hypertonia …………………… Rigidity…………………….. Co-ordination – UL- Finger nose test ………………………Finger test ……………………………...…… LL- Knee heal test ………………………………………………………………………. Involuntary Movement – Fasciculation ………… Tremors…….…….. Chorea ...…….. Athetosis……… Sensory System – Superficial – Touch …………..….. …Pain …………………… Temperature ………………………..…. Deep - Crude touch ……………..… Vibration…………..……Joint sense ………………………….…. Cortical – Tactile localization………. Tactile discrimination……… Tactile extinction ………………... Others ………………………………………………………………………………………….. Cerebellar System – Involuntary Movement……… Nystagmus………Speech …….. Hyptonia………. Tremor……And other ……………………………………………………………… Meningeal signs –Neck stiffness …………… Kernig’s sign……………………………………………. Brudzunski’s sign……………………………………………………………………… Reflexes / Jerks –Glabellar Tap……………. Corneal and Conjunctival reflex………..….…...………… Palatal …………………... Pharyngeal ……………………………………………….... . Abdominal reflex- Upper ………………. Middle ………….. Lower…………….……
- 6. 6 Plantar Reflex ………………..Jaw Jerk ……….……….…Knee reflex……………… Ankle reflex ………………….and others ……….…………………………….………. Others ………… III. Investigation Advised – 1. Blood: ……………………………………………………………………………………………….. ……………………………………………………………………………………………………….. 2. Urine: ……………………………………………………………………………………………….. ……………………………………………………………………………………………………….. 3. Sputum: …………………………………………………………………………………………….. ……………………………………………………………………………………………………….. 4. CSF: ………………………………………………………………………………………………….. …………………………………………………………………………………………………………. 5. X-ray: ………………………………………………………………………………………………….. …………………………………………………………………………………………………………. 6. CT: …………………………………………………………………………………………………… 7. MRI: ………………………………………………………………………………………………….. 8. Others ………………………………………………………………………………………………… …………………………………………………………………………………………………………. IV. Provisional Diagnosis – Specialty code……………………………………………………………………………………………… Package code ……………………………………………………………………………………………….
- 7.
- 8. 8 VI. Daily Notes/ Operation Notes – (Details of surgical procedures)
- 9. 9 VIII. Investigation report(Finding) – IX. Final Diagnosis– Specialty code………………………………………………………………………………… Package code …………………………………………………………………………………
- 10. 10 X. Discharge summary IPDNo.: …………………………………………………………………………….. Patient Name: ………………………………………………………………………. S/o…………………............................................................................M/F………… Admission Date: ………………………..Time of Admission: …………………… Discharge Date: ……………………..….Time of Discharge: ……………………. Attending Physician (Primary doctor): …………………………………………... Treating Physician: ………………………………………………………………… Consulting Physician: ……………………………………………………………… Course during Treatment (From Condition on Admission to Condition on Discharge during Hospital stay)…………………………………………………… ……………………………………………………………………………………….. ……………………………………………………………………………………….. ……………………………………………………………………………………….. ……………………………………………………………………………………….. ……………………………………………………………………………………….. ……………………………………………………………………………………….. ……………………………………………………………………………………….. ……………………………………………………………………………………….. ……………………………………………………………………………………….. ……………………………………………………………………………………….. Final diagnosis with Specialty code: ……………………………………………… Procedures with Package code: …………………………………………………… Treatment advised on discharge: ………………………………………………….
- 11. 11 Details of DoctorsTeam: For Surgical Procedures 1. Surgeon: …………………………………………….............................................. 2. Anesthetist: ………………………………………………………………………. 3. Assistant Surgeon: …………………………………............................................. 4. Pathologist and Radiologist: …………………………………………………… For Medical Procedures 1. Medical Specialist/MO (Treating Physician): …………………………………. 2. Assistant Medical Officer: ……………………………………………………… 3. Pathologist and Radiologist: …………………………………………………… XI. Follow up