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By: Lhims Assistant Team
PC: COMPLAINT- DURATION HPC: ODQ: PMHX: HPT-, DM-, PREV SURGERY, TRANSFUSION, PREV ADMISSION DH...
PRIMARY SURVEY AIRWAY: PATENT WITH NO C-SPINE TENDERNESS BREATHING: SPONTANEOUS, RR: __CPM, SPO2 __...
OE: ADULT __GENDER__ IN NO OBVIOUS RESP DISTRESS NOR PAIN, NOT PALE, NOT JAUNDICE, AFEBRILE, HYD FA...
CONSTIPATION, PASS FLATUS, VOMITING, ABD DISTENTION...
JAUNDICE, PALE STOOL, DARK URINE, STEATORRHOEA, PRURITUS, ANOREXIA, NAUSEA, FEVER, CHILLS, RIGORS CB...
HX: ONSET, PROGRESSION, RISKS (HPT, DM - POLYDIPSIA, POLYPHAGIA, POLYURIA, NEUROPATHY) CELLULITIS: H...
Gnawing, burning, or dull epigastric pain, worse at night or 2-3 hours post-meal, relieved by antaci...
VOMITED TODAY 3 TIMES, COPIOUS ABOUT 30-50MLS PER EPISODE. VOMITUS WAS BILIOUS, NON BLOODY NON PROJE...
STARTED EXPERIENCING PAIN IN THE __SITE__, PAIN WAS __GRADUAL/SUDDEN__ IN ONSET, __THROBBING/SHARP/...
UNDER ASEPSIS AND GA, PATIENT WAS POSITIONED SUPINE, CLEANED WITH POVIDINE AND DRAPED....
EXTENDED UPPER MIDLINE ABDOMINAL INCISION MADE AND DEEPENED TO THE ABDOMINAL CAVITY...
A LANZ INCISION WAS MADE AND CARRIED DEEP TO THE EXTERNAL OBLIQUE APONEUROSIS....
THE INCISION WAS CLOSED IN LAYERS TO THE SKIN. THE WOUND WAS CLEANED AND DRESSED...
IV CIPROFLOXACIN 400MG BDS IV METRONIDAZOLE 500MG TDS IV PARACETAMOL 1G TDS IM PETHIDINE 100MG TDS I...
TAB DORETA 1TAB TDS CAP CELECOXIB 200MG BDS...
ORAL CIPROFLOXACIN 500MG BDS ORAL METRONIDAZOLE 400MG TDS...
POOR STREAM, STRAINING, HEISTANCY, INTERMITTENCY, FEELING OF INCOMPLETE VOIDING, POSTMICTURITION DRI...
PREV TRAUMATIC CATHETERIZATION, FAILED CATHETERIZATION, FALLING ASTRIDE, PREV URETHRAL DISCHARGE, FO...
FMXH OF PROSTATE CA, FMHX OF BREAST CA, HAEMATOSPERMIA, HAEMATURIA, IMPOTENCE, TENESMUS, RECTAL BLEE...
ANAL HYGIENE WAS __, __GOOD__ SPHINCTER TONE, RECTUM WAS __FILLED WITH SOFT STOOL__, PROSTATE WAS PA...
SEEN AT KIDS OPD AGE- __ WEIGHT- __ KG TEMPERATURE- __ *C PULSE– __ BPM SPO2- __ % RDT- __ H...
OE: __GENDER__ NEONATE IN NO OBVIOUS RESP DISTRESS NOR PAIN, NOT PALE, NOT JAUNDICE, AFEBRILE, WELL...
ODQ: FEVER-, VOMITING-, JAUNDICE-, SEIZURES-, POOR FEEDING-, DIFF BREATHING- FAST BREATHING-...
ADMISSION NOTES - SEEN AT NICU 0N _ ............... BABY OF _ DELIVERED VIA _ BROUGHT TO _ .......
PC: COMPLAINT- DURATION HPC: ODQ: PREGNANCY HX: BOOKING WAS AT _, RETRO _, SICKLING _, ANC VISI...
SEEN AT SCD CLINIC AGE 11 YEARS VITALS TEMP __ *C RR: __ CPM SPO2:__ % PULSE: __ BPM WT __ KG KN...
ODQ : DARK COLOURED URINE- JOINT PAINS- FEVER- ABDOMINAL PAIN- JOINT SWELLING- YELLOWISH DISCOLOURAT...
ODQ- POOR FEEDING-, IRRITABLE-, , CHILLS-, RHINORRHEA+, NASAL CONGESTION-, COUGH+, DIFFICULTY BREA...
SUSP AMOXICLAV __ MG BDS x 7DAYS SYR PARACETAMOL __ MG TDS x 7 DAYS ASCOBIC ACID __ MLS x 14 DAYS SY...
TO DO FBC,G6PD, BLOOD GROUPING,HB ELECT,BF FOR MPs, BUEnCR, LFT,BLOOD CS, SERUM MAG, SER CALCIUM...
AGE __ YEARS VITALS TEMP __ *C RR: __ CPM SPO2:__ % PULSE: __ BPM WT __ KG...
