uro-health clinic filedr. divakar dalela mbbs, ms (surgery), mch (urology), fics (urology), fams...
TRANSCRIPT
Uro-Health Clinic2/503, Ground floor, Vikas Nagar, Lucknow-226 022
OPD CASE FILE MALE
Name Age
Phone
Address
Reg.No. Date Rcpt. No.
Qksu % 0522-2739099, 2739499, 3207964, eks- % 9235401984
Dr. Divakar DalelaMBBS, MS (Surgery),MCh (Urology), FICS (Urology), FAMS (Urology)
Consultant Uro Surgeon
Professor & Former HeadDept. of Urology, KG Medical University, Lucknow
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Qksu % 0522-2739099] 2739499] 3207964eksc- % 9235401984
E-mail : [email protected]
Name : Age/Sex :
Uro-Health Clinic
Co-morbidities
Main Diagnosis
Histopathalogy
Dates of Operations/Procedures
Prof. D. Dalela, MS, MChReferred by :
With acknowledgments
Aforesaid information is not valid for medical-legal purposes.
Drug AllergiesName of Drug Type of Allergies
Previous Medication
Name & Dose of Drug Taking Since Prescribed by
Prof. D. Dalela, MS, MCh
Aforesaid information is not valid for medical-legal purposes.
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Clinical HistoryLower Urinary Tract Symptoms
Thin Stream
Slow Stream
Hesitancy
Terminal Dribble
Incomplete voiding
Urinary retention
Previous Cathet.
Diurnal Freq.
Nocturia
Urgency
Urge Incont.
Dysuria
Urinary Burning
Bed wetting
Upper Urinary Tract Symptoms
Flank Lump
Oliguria/anuria
Graveluria
Flank Pain
Fever
Oedema
PME
ED
Infertility
Post eja. burning
Urethral discharge
Haemospermia
Haematuria
Pyuria
Chyluria
Constipation
Frequent Stools
Backache
Sexual Symptoms
Misc. Symptoms
Prof. D. Dalela, MS, MCh
Aforesaid information is not valid for medical-legal purposes.
Previous Illnesses/Hospitalization
Addictions Family History
Clinical Examination
Abdomen
Pulse :
Edema :
BP :
Weight :
DRE
Anal tone/sensations
Prostate tenderness
Prostate Nodule
Prostate Size
Prof. D. Dalela, MS, MCh
Genitalia
Prepuce
Glans
Meatus
Shaft
Scrotum
Initial Plan
Aforesaid information is not valid for medical-legal purposes.
Investigations ChartBlood Group HBsAg HCV HIV
Prof. D. Dalela, MS, MCh
B. Sgr. P
Date
Hb
TLC
DLC
B. Sgr. F
B. Sgr. R
Creatinine
Uric Acid
Na
K
Aforesaid information is not valid for medical-legal purposes.
Date
PT
APTT
BT/CT
S Calcium
S PO4
S PTH
Bilirubin
Alk Phos
SGPT
Total Pro t.
Albumin
S.TSH
S. T3/T4
SGOT
PSA
IVPUSG
Date UT Pros./Ut. PVRU
Prof. D. Dalela, MS, MCh
Aforesaid information is not valid for medical-legal purposes.
CYSTOSCOPY
URODYNAMICS
Date%
Left Kidney Right Kidney
Drainage % Drainage
RENAL SCAN
RGU/MCU
CT/MRI
UROFLOW
Date Volume PFR AFR Time
Prof. D. Dalela, MS, MCh
Date Organism Main Sensitivity
Date Pus Cell RBC,s Albumin Chy/Trig
Cardio Respiratory Work up
Aforesaid information is not valid for medical-legal purposes.
Urinalysis
Urine C/S
Urologic DiagnosisProf. D. Dalela, MS, MCh
Up
per
Tra
ct
Sta
tus
Aforesaid information is not valid for medical-legal purposes.
Lo
wer
& G
en
ital Tra
ct
Sta
tus
Aforesaid information is not valid for medical-legal purposes.
Progress & Treatment Prof. D. Dalela, MS, MCh
Clinical Progress
Plan
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Clinical Progress
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Progress & Treatment Prof. D. Dalela, MS, MCh
Clinical Progress
Plan
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Progress & Treatment Prof. D. Dalela, MS, MCh
Clinical Progress
Plan
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Progress & Treatment Prof. D. Dalela, MS, MCh
Clinical Progress
Plan
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Plan
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Aforesaid information is not valid for medical-legal purposes.
Progress & Treatment Prof. D. Dalela, MS, MCh
Clinical Progress
Plan
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Aforesaid information is not valid for medical-legal purposes.
Progress & Treatment Prof. D. Dalela, MS, MCh
Clinical Progress
Plan
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Clinical Progress
Plan
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Aforesaid information is not valid for medical-legal purposes.
Progress & Treatment Prof. D. Dalela, MS, MCh
Clinical Progress
Plan
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Clinical Progress
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Visit Record
Date S.No. Rcpt. No. Signature