BIODATA OF THE PATIENT

Name of the Patient : Geetaben S Gamit

Age : 20 Years
Sex : Female
Register No/Inward No : 21428
Bed No :5
Admission date : 22-3-17
Doctor’s Unit : Dr. Bhavin sir
Ward : Emergency ward
Marital status : Unmarried
Religion : Hindu
Education : Student
Occupation : Study
Monthly income : 10000 Rs/ month
Address : Kikvad, Bardoli, Surat
Diagnosis : Appendicitis
Operation Name :-
Operation date :-
Height : 160 cms
Weight : 45 kg

HISTORY OF THE PATIENT

1). Chief complaint:
Pain in abdomen
Dyspepsia since 3 days
Loose stool
Nausea
Vomiting
2).Present history:
Patient was alright 3 days back when she experienced the symptom came to hospital
with complaints of pain in abdomen with it was increased progressively, dyspepsia and vomiting
with loose stool
3) Past history:
a) Past medical history: No any past medical history significant like TB, Asthma, and HTN.
b) Past surgical History: - No any past surgical history of the patient.
4) Family history:
Family Tree:

Sureshbhai Heenaben
Mention each symbol description:
: Male

: Female

: Female Patient

Family composion
Name of family member Age/sex Relation with patient Health status

Geetaben 20/F Self Unhealthy

Sureshbhai 50/M Father Healthy
Heenaben 48/F Mother Healthy

5) Personal history:
• Diet : Veg and Non- veg
• Sleep/rest : Sleep pattern disturb due to Pain
• Micturation : Normal
• Bad habits : No any bad habits.

6) Socio-economic history:
They belongs to middle class family because the monthly income is 10000 Rs per month.
Relationship with the family member is good also with the other family member and societal
member.

PHYSICAL EXAMINATION
VITAL SIGN:
TEMPERATURE : 98.6F
PULSE : 76 B/ MINUTE
RESPIRATION : 22/MINUTE
BLOOD PRESSURE : 110/70MM HG
GENERAL APPERANCE:
• Body image : Thin
• Health : Unhealthy
• Activity : Dull
MENTAL STATUS:
• Consciousness : Conscious
• Look : Anxious
POSTURE:
• Body curves : No any kyphosis, lordosis
• Movement : Normal
SKIN CONDITION:
• Color : no any cyanosis
• Texture : No any wrinkles
• Temperature : Normal
• Lesions : No any lesions are present
HEAD & FACE:
• Scalp : No any scar, dandruff present
• Face : No any edema, anxious look
EYES:
• Eyebrow : No any dandruff present
• Eye lashes : No any infection present
• Eyelids : No any discharge present
• Eye balls : Both eyes coordinated
• Conjunctiva : No any redness
• Sclera : No any jaundice
• Pupils : Reactive to light
• Vision : Normal
EAR:
• External ear : No any discharge from external ear
• Hearing : Normal
NOSE:
• External nares : No any discharge from external nose
• Nostrils : No any nasal septum deviation

MOUTH & PHARYNX:

• Lips : No any cracked lips, dry
• odour of the mouth : No any foully smell coming
• Teeth : No any dental caries
• Tongue : No coated tongue
NECK:
• Lymph node : Not palpable
• Thyroid gland : Not palpable
• Range of motion : Present
 CHEST:
• Thorax : Normal in size and shape
• Breath sound : Normal Bio vesicular sound present
• Heart : Normal in size and shape
ABDOMEN:
• Observation : No any scar lesions present
• Auscultation : Audible tympanic sound present
• Palpation : There is mass, tenderness is present
• Percussion : there is fluid or gases are present
EXTREMITIES:
• Upper extremities : No any deformity in upper extremities.
• Lower extremities : No any deformity in lower extremities.
REFLEXES:
Biceps: Present
Triceps: Present
Patella: Present
INVESTIGATION:-

TYPE PATIENT REPORT NORMAL VALUES IMPRESSION

BSL RANDOM 128 mg/dl Upto 150 mg/dl

HEMOGRAM 12.5% 13-18 mg/dl
WBC 26,500/cumm 4000-11000-cumm

LFT
SR. BILIRUBIN LEVEL 2.0mg/dl 0.2-1.0mg%
DIRECT 0.6mg/dl 0-0.3mg%
SGOT 12 5-40IU/L

RFT

BLOOD UREA 28mg% 10-45mg%

SR. CREATININE 1.4meq/l 0.9-1.2meq/l

SERUM
ELECTROLYTE 121Meq/l 135-145meq/l
Sr. SODIUM 2.6Meq/l 3.5-5.5 meq/l
SR. POTASSIUM
URINE ROUTINE
NORMAL

USG/CT scan/MRI/Biopsy: USG- APPENDICITIS INFLAMMATION SUGGEST

 MEDICATION

SR. MEDICATION ROUTE DOSE FREQUENCY

NO.
1 Inj.c-tri IV 1gm 10, 10

2 Inj. Emset IV 4mg 6,2,10

3 Inj. Pan IV 40mg 10,10

4 Inj. Morphine IV Sos ----

5 Tab. Vit-c Oral 500 9,3,9