PROFORMA

Name: Age: Sex:

Address: DOA: DOD:

Presenting complaints:

Chestpain

Site, radiation:

Character:

Duration:

Dyspnoea:

PND:

Neurological deficit:

Loss of consiousness

Cranial nerve deficit:

Motor/sensory deficit

Pedal oedema:

Oliguria, Anuria
Visual deficit

Headache

Vomiting

Others

Past history:

Hypertension

Duration: treatment

Medication discontinued :yes/no

Complications related to hypertension in the past:

Any other associated illness:

Other relevant past history:

General examination

Pallor icterus

Cyanosis

Clubbing

Oedema

Lymphadenopathy
 Vital signs:

Pulse rate: Respiratory rate: Saturation

Blood pressure on presentation:

Blood pressure after one hour:

Blood pressure after 24 hours:

Blood pressure at discharge:

Respiratory system:

Inspection:

Palpation:

Percussion:

Auscultation:

Cardiovascularsystem:

Inspection:

Palpation:

Percussion:

Auscultation:
Abdomen:

Inspection:

Palpation:

Percussion:

Auscultation:

Central nervous system:

Higher mental functions:

Cranial nerves

Right left

Motor system

Bulk UL:

LL:

Tone UL:

LL:
 Power UL:

LL:

Deep tendon reflexes

Plantar:

Sensory system:

meningeal signs:

Fundus:

Clinical diagnosis:

Investigations:

HB%:

TC: DC: ESR:

Urine analysis: micro/macroalbumuria

Random blood sugar:

Serum urea:

Serum creatinine:

Serum cholesterol:

Triglycerides:

LDL cholesterol:
HDL cholesterol:

Serum sodium:

Serum potassium:

Serum chloride:

ECG:

Ultrasound scan (abdomen)

CT scan(head)

2D Echo

Diagnosis: