CASE SHEET

(CASE/96886/AP5148105)

PATIENT DETAILS

Patient Name U Suresh Card No JAP121602700045/04

Age 38 Years 4 Months 1 Days Gender Male
Phone Number 9390420298
Address 1-103, BC COLONY - 515741 Maritial Status Married

HOSPITAL & ADMISSION DETAILS

IP Number 1484 Admission Date 02-05-2022 Admission Type Planned

SRI GAYATHRI 12/2/883, ANANTAPUR -

Hospital Name Contact Address Doctor name Dr Mdhusudhan
HOSPITL 9642211796

Medico Legal Case No Discharge Date

GENERAL EXAMINATION FINDINGS

Height (in cm) 169 Weight (in kg) 40 BMI 14.0

Respiration Rate 22 BP Lt.Arm 120 / 80 BP Rt.Arm 120 / 80

Pulse Rate 79 Temperature C F 96.4 Pallor Yes No

Lymphadenopathy Yes No Oedema In Feet Yes No Malnutrition Yes No

Clubbing Of
Cyanosis Yes No Yes No Dehydration Yes No
Fingers/Toes

ICTERUS/Jaundice Yes No

PERSONAL HISTORY

Habits/Addictions: No Habbits / Addictions are selected

Known Allergies:

Allergic to Medicine: Yes No

Allergic to Substance other than

Yes No
medicine:

FAMILY HISTORY

Family History:

Diabetes Hypertension Psychiatrist Illness Cancer

Stroke Tuberculosis Asthma Heart Disease

 Any Other Hereditary Disease

Any Other

ADMISSION MEDICAL DETAILS

PAIN AND SWELLING RT DIRECT

History of Present Illness PAIN AND SWELLING RT DIRECT HERNIA Past History
HERNIA

Examination Findings USG BLOOD TEST Provisional Diagnosis RIGHT INGUINO SCROTAL HERNIA

Investigations :- Routine ULTRA SOUND ABDOMIN Special ULTRA SOUND ABDOMIN

Final Diagnosis Rt Inguinal hernia

THERAPY/SURGERY DETAILS

Category Sub Category Surgery/Therapy Remarks

GENERAL SURGERY ABDOMEN (S1.3) Hernioplasty - Indirect inguinal hernia (S1.3.1.10.2) NILL

PRE-OPERATIVE CLINICAL NOTES

Pulse Heart Fluid Fluid Blood

Clinical ID Temperature Respiratory Lungs Invest Date Ward Type Remarks Haemoglobin
Rate Rate Input Output Pressure
DICLO,RAN
CC74300251 39 70 23 S1 CLEAR 1800ML 1700ML 120/80 02/05/2022 GeneralWard 13
TAC

Clinical ID Abdomen Nervous System SPO2 Specialists Referred

CC74300251 SOFT NORMAL 98 -

CLINICAL NOTES SUB CUTANEOUS INSULIN CHART

Insulin Insulin
Plasma Blood Plasma Blood Plasma Blood Plasma Blood Insulin Insulin
Doctor Dosage Dosage
Clinical ID Date Glucose Glucose Glucose Glucose MN Dosage Dosage
Name BBF(7:00 BD(7:00
BBF(7:00 AM) BL(1:00 PM) BD(7:00 PM) Rate SR(1:00 PM) MN
AM) PM)
DR N
CC74300251 02/05/2022 ANANDA - - - - - - - -
KUMAR

CLINICAL NOTES MEDICATION CHART

Main Chemical
Therapeutic Main Pharmacological Chemical SubGroup Route Strength Medication
Clinical ID Group Substance Route Strength Dosage
Group Name SubGroup Name Name Type Type Period
Name Name
Other Drugs For
Musculo Other Drugs For Disord Other Drugs For Dis
Disorders Of The Hyaluronic Inhal Aeros Milligra
CC74300251 -Skeletal ers Of The Musculo-Sk orders Of The Musc 100 mg BD 1
Musculo-Skeletal Acid ation ol m (mg)
System eletal System ulo-Skeletal System
System
 COMORBIDITIES

No comorbidities added for this case

OPERATION / TREATMENT DETAILS

DR NAGARAJU NAIK,
Surgeon Name & Reg No DR MADHUSUDHAN, APMC58800 Anesthesiologist Name & Reg No
APMC81473

Surgery Date 04-05-2022 Anesthesia Type Spinal

Surgery Start Time 18:11 Surgery End Time 18:30

PROCEDURE DETAILS WITH SPECIFIC INTRA OP FINDINGS

Incision Type VOLAR POSITION Swab & Instruments count 5

Post Operative Instructions STABLE Sutures Ligatures VICRYL,ETHILON

Blood loss 3ML Drainage count 10

Condition of the Patient at the time of Shifting GOOD

Specimen Removed No

Complications if any No

POST CLINICAL NOTES MEDICATION CHART

Post Clinical Notes drugs list not found for this case