Physician Notes

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Patient's Accessment

Complaint :
Examination Time :		B.P :		Pulse /min :		R.R /min :		Temp (C) :
General Appearance :
Head & Neck :					Chest :
Heart :					Abdomen :
Musculoskeletal :					Extremities :
Conscious Level :
Pain Score [Vas]					0 = No Pain , 10 = Severe Pain

Past Medical History :
Allergies :

Examination By System

Neurological

Respiratory
Spontaneous Ventilation	Yes No
Asymmetry	Yes No
Wound, bruises	Yes No
Trachea Central	Yes No
Cyanosis	Yes No
E.T.T	Yes No
SURGICAL	Yes No
Comments	Yes No

Respiratory
Abdomen	Firm Firm Distended Tender
Bowl Sounds	Yes No
Wound, Bruises	Yes No
Vomiting	Yes No
Diarrihea	Yes No
Constipation	Yes No
Comments	Yes No

Scalp Injury	Yes No
Facial Injury	Yes No
Neck Injury	Yes No
Black Eye	Yes No
Skull Fracture	Yes No

Vomiting	Yes No
Convulsion	Yes No
Motor Deficits??	Yes No
C.S.F	Yes No
Blood	Yes No

Comments	{$physician_report.neurol_comment}

Genitourinary N/A
Dysuria	Yes No
Hematuria	Yes No
Anuria	Yes No
Distended Bladder	Yes No
Urine Color	Normal Dark Dilute Others
Comments	{$physician_report.gen_comment}

Musculoskeletal N/A
Affected Part	{$physician_report.affected}	Mobility	{$physician_report.mobility}
Color	{$physician_report.color}	Comments	{$physician_report.muscu_comment}

Gyne N/A
Pregnancy		Term
Miscarriage		FHR
Discharge		Bleeding/amount
Comments	{$physician_report.gyne_comment}

Investigations

Hb%	WBC	Platelets	Na	K	GOT	GPT	Cardiac Enzymes	PT	PTT	Radom Blood Sugar

Others :
X- Ray :
Provisional Diagnosis :
Consulting Other Specialist :
Final Diagnosis :
Treatment and Managment :

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