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    Right Radial Head Fracture

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    hemanarasimha gandikota
    1. The document appears to be operation notes from a surgery. It includes information such as the surgeon, anesthetist, date and times, diagnosis, procedure performed, operative findings, postoperative treatment and samples taken. 2. The procedure performed was a left knee arthroscopy. Operative findings included torn medial meniscus and cartilage damage. 3. Post-operative treatment included analgesics and physiotherapy advice. No complications were noted.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Right Radial Head Fracture

    Uploaded by

    hemanarasimha gandikota
    10 views6 pages
    1. The document appears to be operation notes from a surgery. It includes information such as the surgeon, anesthetist, date and times, diagnosis, procedure performed, operative findings, postoperative treatment and samples taken. 2. The procedure performed was a left knee arthroscopy. Operative findings included torn medial meniscus and cartilage damage. 3. Post-operative treatment included analgesics and physiotherapy advice. No complications were noted.

    Original Description:

    About right radial head fracture

    Original Title

    right radial head fracture

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    1. The document appears to be operation notes from a surgery. It includes information such as the surgeon, anesthetist, date and times, diagnosis, procedure performed, operative findings, postoperative treatment and samples taken. 2. The procedure performed was a left knee arthroscopy. Operative findings included torn medial meniscus and cartilage damage. 3. Post-operative treatment included analgesics and physiotherapy advice. No complications were noted.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    10 views6 pages

    Right Radial Head Fracture

    Uploaded by

    hemanarasimha gandikota
    1. The document appears to be operation notes from a surgery. It includes information such as the surgeon, anesthetist, date and times, diagnosis, procedure performed, operative findings, postoperative treatment and samples taken. 2. The procedure performed was a left knee arthroscopy. Operative findings included torn medial meniscus and cartilage damage. 3. Post-operative treatment included analgesics and physiotherapy advice. No complications were noted.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 6

    PESIMSRIMRF/025/DEC14

    PES Institute of Name : . . . . .


    Medical Sclences UHID No..... IP No..SA.
    &Research
    PES Age:.Gender :M/F Ward:.s..Date &Time .
    OPERATION NOTES (Theatre.....)
    Surgeon in charge
    D Veeeh o surgical Scrub List
    Anaesthetist 1st Assistant
    Pre OP Dlagnosis
    Assistant
    Starting time
    Scrub Nurse
    Finishing time
    Floor Nurse
    Clinical diagnosis
    Indication for surgery Type of Anaesthesia
    slodtA
    Name of the
    Procesune:
    Post-op diagnosis
    fecte
    Patient position Eled / Emerg. :

    Incision Lt
    Operative findings

    An nebn ot s2e &antleu al olea


    Operative steps

    Clevta

    CGafned J Can
    Post-op treatment

    Adoice

    Frozen section histology No

    Report
    Neomd

    Unit of blood / products transfused:

    Samples for laboratory examination :

    PrakashK
    Bhanu
    DrAPMCJFMR/101983
    rGOrthopaedica Signature (surgeon
    PESIMSR.KUPPAM

    Kuppam -517425, Chittoor Dist.,


    PESIMSRIMRF/003/DEC 14

    Name:
    PES Institute of
    Medical Sciences UHID No...A. ..P N o . . k .
    & Research Age: Gender:M/F Ward/Unit :
    PES
    CLINICAL HISTORY /INITIAL ASSESSMENT (IP)
    Date History obtainedfrom: Patient Relative Others

    1. COMPLAINTS AND DURATION:


    clo slba

    2. HISTORY OF PRESENT ILLNES:

    HISTORY OF PAST ILLNES:


    1 Diabetes No Yes Details:

    2 Hypertension No Yes Details:


    3 Heart disease No Yes Details:
    4 Stroke No Yes Details:
    5 Cancer No Yes Details:
    3 Tuberculosis No R Yes Details:
    Asthma No Yes Details:
    Transfusion of Blood
    or Blood Products No Yes O Details:
    Past Surgery No K Yes Details:
    0 Other:.
    Page 1 of 4
    4. PERSONAL HISTORY:
    4.1 Marital Status:Single
    4.3 Diet Veg L Non VegI
    4.6 Bowels: Regula
    Dolaie
    4.6 Medication Allergies
    4.67 Other Allergies No Yes J
    4.8 Habits/ Addictions:
    a) Alcohol -Teetotaler
    b) Tobacco -Snuff H Chewable
    c) Drug abuse
    Delaile
    d) Betel Leaf (Paan) No Yos

    5. FAMILY HISTORY:
    Diabetes No Yes Deteils:
    5.1
    Hypertension No Yes Details:
    5.2
    5.3 Heart disease No Yes Details,
    5.4 Stroke Nó Yes Details:
    5.5 Cancer N6 Yes Details,
    5.6 Tuberculosis
    No Yes J Details:
    5.7 Asthma No Yes Details:
    5.8 Hereditary Disease:
    5.9 Psychiatric illness: m
    5.10 Any other:

    6. TREATMENT HISTORY &CURRENT MEDICATIONS:


    1
    REVEW OF SYSTEMS (Please
    circle as
    (a) Fever
    appropriate)
    Weight changes None /
    Night Sweats
    Loss /Gain . Kgs over
    ()
    Respiratcory -cough, dysponea, wheeze
    (e)
    Cardiovascular - palpitation, chest pain, dyspnoea, edema,
    (
    Gastrointestinal -
    abdominal pain,
    syncope
    Vomitings, jaundice, diarrhoea,
    constipation
    bleeding PIR, hematemesis
    (g)
    Neurological weakness, numbness,
    -
    Others: headache, fits, altered sensorium

    YSICAL EXAMINATION: Appearance


    General Examination: Pulse
    Comfortable Anxious Distressed
    Imm BP: mmHg. RR: Imin Temp: (F). Sp02: %
    Build. MaduNutrtions Status..ee ... BMI

    Pallor Jaundice Clutbbing Cyanosis Edema


    Conscious level: Alert &Oriented Confused Drowsy Unconscious
    Lymphadenopathy
    Glasgow Coma Scale: 15
    PAIN: No Yes If yes, indicate score from scale: h10

    PAIN ASSESSMENT SCALE


    0 2 3 4 5
    No Just 6 8 10
    pain noticoable
    MIld
    pain
    Uncomfortable
    paln
    Annoying
    pain
    Moderate Vust Strong Severe Hortible Worst
    pain pain bearable pain pain pain pain
    pain

    Location : Character:( Sharp IDull / Aching /Burning /Stabbing


    Duration: Acute (<6Weeks ) Chronic (>6Weeks )O
    Acentuating &relieving factors:

    CLINICAL EXAMINATION SYSTEM

    SLelly
    Jendun
    }dect
    Page 3 of 4
    INVESTIGATIONS DONE PRIOR TO ADMISSION INVESTIGATION ORDERED
    CAC, SSR, RAS, Cxk, 4
    RM,sls

    DIAGNOSIS
    Rigt Rdl hed fech

    CARE PLAN

    Dprepsulels
    ) sleek Susll fyako

    PrakashK
    "RPMCEMR/101983
    Bhanu
    ) Aeke fi-gunak
    pr aedics
    rG ÞfthoR?edi
    PESIMSR. KìIPAM,
    Date &Tine

    Print Name: Dr. Signature :


    Kuppam - 517425, Chittoor Dist., A.P

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