HR15050003

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1. Particulars of the patient

Name shimul
Age 18 years
Sex F
Religion islam
Ocupation student
Address jhinaidah
Contact
Close Relative Contact
Weight
BMI
Blood Group
Known Drag Allergy none
Core Diagnosis fallots triology
Estimated 10 Years CVD Risk
Rx Status
Sufferings

 

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2. Chief Complaints

Asymptomatic v
Chest Discomfort v
Breathlessness v
Dyspnoea Orthopnoea v
PND v
On rest v
Limitation of activity v
Palpitation v
Oedema v
Claudication v
Dizziness/Syncope v
Others (stroke/abdominal pain /undue tiredness)

3. Quantification of symptom

No problem at normal place – Grade 0
Able to work as far as like but takes his time – Grade I
Block limitation – Grade II
Dyspnoea on mild exercise (kitchen to bathroom) – Grade III
Dyspnoea at rest – Grade IV

4. NYHA functional classification of CHF

Class I- no FDP in ordinary work
Class II- FDP in ordinary work
Class III- marked limitation in less than ordinary work
Class IV- unable to carry out any physical activity
Class V- symptom of cardiac insufficiency even at rest

5. Duke activity status index (drop down menue)

Eating, dressing, dish washing, walk around home (1-4 met)
Climbing 2 stairs/fast walk (6.4km/hr)- (4-10 met)
Short run/golf (6MET)
Sports (>10METS)
Able to exercise (>4MET)

6. Past illness past Rx history family history (family members, familial hyperlipidaemia, DM,HTN) social and personal history

7. Physical examination

Physical examination

  • general

routine

source of infection

site of surgery

  • systemic
  • surgery related(site of surgery /any complication arose from offending pathology)
  • specific(suitability of positioning during surgery)

(I). General

  • routine

(An………Jx…….Cyn…….club…..koyl…Leuk xan)A nutritional status

Pulse…………rate 78………rhythm……R………vol…………N………… ……RR delay………A…………RFD(rt/lt)………A……cond of vesel wall………N…………collapsing…… ……………………………A……………………………….. BP……120/80mmHg………in rt(v )/left arm (v ) supine(v ) /sitting(v ) /standing at (both ) @ AM/PM Temp… 99F….JVP…NR….oed… A(pitting/non pitting)….

RR………26breaths/min…………….. LN………………………

  • source of infection(teeth,face,feet,leg ulcer)
  • site of surgery

(2)SYSTEMIC

I. Precordium/chest

a..Inspectioni.Deformityii.Skin conditioniii.Visible apex beat @………………ICS (normal/ deviated)b.palpationi.Apex beat(Nv / absent /tapping (commence just after carotid/palpable S1)/ apical heave /diffuse/double beat )ii.Heave-Left parasternal heave-Aiii.Thrill (aortic/A2 pulmonary/P2)iv.Lateral PMI displacement-A

c.Percussion for cardiac dullness

d.Auscultation S1+S2(Normal split)+Ex0+Ad0+M0

II. Respiratory

a.Inspection(from front-side and back)i.Shape Nv/barrel/indrawn/pegion chest/excavatum/flatKyphosis/scoliosis/hyper scoliosischestii.indrwing-A/iii.symmetry-viv.skin condition-/scar/engorged vein-Av.intercostals recession/Av.use od accessory muscle-A
b.palpationi.tracheal positionii.maximum chest expansioniii.total chest expansioniv.apex beatv.vocal fremitus

c.Percussion tympanic/hyper resonant/resonant/impaired(CCF)/dull(CCF)/stony dull(fluid)

d.Auscultationbreath sound i.bronchial(no gap-tubular-insp=exp)/(ii.vesicular-steady increase in insp and diminishes 1/3rd of exp)vocal resonance (bronchophony/whispering pectoriloquy/aegophony)added sound (Ronchi in exp(asthma) or insp+exp (secretion/sol/COPD) Crackles(secretion/AWO Rub Vesicular with prolonged expiration wheeze

 

Site VF/VR Percussion Auscultation Then auscult After caugh
Ant (SCS, clav, ICS, 2-6thICS) normal(N) resonant(R) vesicular(V)
normal(N) resonant(R) vesicular(V)
normal(N) resonant(R) vesicular(V)
Lat (4th-7thICS) normal(N) normal(N) resonant(R) resonant(R) vesicular(V) vesicular(V)
normal(N) normal(N) resonant(R) resonant(R) vesicular(V) vesicular(V)
normal(N) normal(N) resonant(R) resonant(R) vesicular(V) vesicular(V)
normal(N) normal(N) resonant(R) resonant(R) vesicular(V) vesicular(V)
Back (TPZ, supraspinous space, 4-5cm below of spine upto 11th rib) normal(N) resonant(R) vesicular(V)
normal(N) resonant(R) vesicular(V)
normal(N) resonant(R) vesicular(V)

III. Neck Airway patency

SAMSOON and YOUNG modified mallampati test(sitting infront and tongue potruted)

  • fauces pillars soft palate uvula visible-Grade-1
  • fauces soft palate uvula seen Grade-2
  • soft palate seen (S) Grade-3
  • hard palate seen(H) Grade-4

JVP(pt at 45degree reclined,face to opposite side-behind SCM/between 2 heads of SCM)

The vertical height of pulsation to sternal angle in cmElevation-abd-jugular reflex-(HF)Elevation(PE)Elev+prominent Y(pericard eff) Elev+lost pulsation-SVC obst Giant a (a-atrial contraction)-TS Giant V-(v-opening of tricuspid)TR Cannon-CHB Carotid

IV. Vascular

Artery Right Left
ADP v v
ATA v v
PTA v v
POP v v
FEM v v
AA v v
RAD v v
Brach v v
Ax v v
Caro v v
Trndelenburg
Allen’s
Burgers
Sephana varix
Tap test
Torniquet test
Parthes test

Peripheral Pulses

a.INSPECTION
leg
Arterial Insufficiency- thin shiny/sunset appearance/lost hair/wasting

Venous insufficiency-tortuous S/C vein/venous star/sign of insufficiency in gaiter area/oedema/haemosiderin deposition/lipodermatosclerosis/eczeema/ulcers
Nail-brittle/transverse ridges
Gangreene-color…………../dry/wet/ulceration/oozing/discharge…………line of demarcation
Vein-guttering/varicosity
Caugh test

Ulcer:
b.PALPATION
Temparature
Gangreene-tenderness……crepitation……..
Perigangrenous area-oedema(pitting)
Palpable caugh impulse
Tap/shwartz test
Muscle girth
Capillary refilling
Venous refilling
Reactive hyperaemia
Burger’s (20-30-45-60-90)
Capillary filling
SLR
Pulses
ABPI
Torniquet test/Trendelenburgs test
Perthes test
Distal joint
Proximal LN
sensory
abdominal examination
Neurological examination

 

V. Incision site/operation site examination Femoral veins

VI. Abdomen Enlarged liver tender liver pulsatile liver Kidney(bimanually palpable/ballotable) Renal bruit

VII.Neurological examination Motor sensory (for DM)

1.General
a. Dominence…./fasciculation/tremor/screening(pronator drift/pseudoathetosis/postural tremor)
b.Cognitive(alertness/orientation/attention/memory-antegrade-retrograde/frontal execution function)
c.Co ordination(finger to nose/dysdiadokinesis/heel shin/sensory ataxia)
d.Neck rigidity
e.Kernig’s sign
2.Cranial nerves
3.Motor
a.Girth
b. Tone-pyramidal(rapid flexion extension of elbow/supination catch/Hoffman’s/brisk flick at knee causing catch/ankle clonus)
Extra pyramidal-(slow flexion and extension)
c.Strength
d.grading
e.Reflexes
superficial
deep
4.Sensory
5.Gait
6.Romberg’s

 

(3).SURGERY RELATED(site of surgery /any complication arose from offending pathology)

(4).SPECIFIC(suitability of positioning during surgery)

 

8. Provisional diagnosis

ASD

9.Differentials

VSD

TOF

10. Investigations

depends on 1.type of surgery 2.patient(depending on natural history/incidence…sickle cell anaemia is investigated in afro americans, TB in south asians) 3.comorbidities

a. For confirmation of diagnosis

b. For treatment option work out

c. For fitness

d. For prognosis/followup of comorbid diseases

e.for detection of target organ damage

 

 

 

 

 

11. Final diagnosis

trialogy of Fallot’s

Complex congenital cyanotic heart disease -triology of Fallot’s(ASD+PS+RVH)+PDA with shunt reversal (Rt to Lt)

pre operative planning

  • record all relative informations
  • optimise patient conditions
  • choosing surgery with minimal risk and maximum benefit
  • anticipate and plan for adverse events

pre operative management

  • capacity-baseline organ function
  • optimisation-lifestyle modification,medication,specialist referral
  • alternative-minimal impacting procedure and appropriate post operative care
  • theatre preparation-timing,team work,special instruments arrangements
PLAN:a. further investigations (Echo/markers/CT angiogram/angiogram/perfusion/lipid profile/diabetic profile)/b.clinical correlation neededc.follow up programmed.councelling and assurancee treatment(life style modification/medical/interventional/surgical)i. general managementii.symptom alleviationiii.control of comorbiditiesiv.definitive management plan and executionpre operative control of comorbidities

plan proper with estimation of predictive risk

back up plan with predictive risk

intra operative precaution

planning for post operative specific care

revised risk assessed after control of co morbidities

consent taken after explanation assurance and alternative option discussion with back up plan and predictive risk

 

Rx protocol/operationName of operation (……………………………….)(cat of operation………) ASA (………………….) With preoperative control of co morbidities Preop control of HTN Preop control of DM Preop control of hypercholesterolemia With preoperative avoidence of smoking atleast 1 month prior(that decrease the risk by 30%) And avoidence of OHA and ASPIRIN With atleast 2 units fresh screened crossmatched human blood in hand And properplanning of specific post operative precaution and treatment plan

With proper risk assessment work out1.perioperative risk of re infarction2.with predictive risk of dying on waiting list(NZ score)3. with predictive risk of dying in hospital(APACHE III)4 with predictive risk of specific illness(Glasgow and Ranson criteria)5. with predictive risk of operative severity score(POSSUM)6. with predictive risk of operative mortality(Euro score)7. with predictive cardiac risk of non cardiac surgery(RCRI)8. with predictive risk of survival after noncardiac surgery in patient of IHD and CHD9.with 30days post operative mortality prediction10.CRASH

12. Rx plan

13. Operation planning

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14. Next visit with date mentioned

Schedule Date and pre requisit
2nd visit after 7 days
3rd visit after 14days
4th visit after 1 month (Any high normal BP visit after 3 months)
Other

15. Operation note

15. Peri operative events

Period Date Event Complication Intervention Follow up Rremarks
PreOP
Per op
Immediate
Early
1st POD
2nd POD
3rd POD
4th POD
Other
Extubation
Weaning
Drain off
Stich off
Discharge
Late

16. Follow up (FU)

Vitals 1st visit/preop FU1/post Op FU2 FU3 FU4 Remarks
Symptom
Sign
Symtom quantification
Co morbidities
Risk assessment

17. Radiological Follow up

Investigations 1st visit/preop With date FU1/post Op With date FU2 With date FU3 With date FU4 With date Remarks
Xray
ECG
Angiogram
CT angio
Others

18. BP follow up (Graphical presentation 1.systolic 2.diastolic) Target BP…………………………..<140/<80(non diabetic/non CVD)…………………….<130/<80(diabetic/CVD) Avg HBPM……………………Clinic BP(after 5mins rest)……………………………………………………………………………… Avg M1+M2+E1+E2 from2nd to 7th day (lowest just after walking up)

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19. DM follow up (Graphical presentation BM, 2HABF, BD)

Previous FBS………..2HABF…………………RBS……………………….OGTT………………….HbA1c……………………..

Target……………………………………………………………………………………………..

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20. Documents

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History taken by Examined by Investigation reviewed by

Plan given by

Supervised by

 

case report

 

 

hrids

hhrids.com/HR14110001

 

 

1.presentation

a.particulars

 

b.onexamination

 

c.provisional diagnosis

d.differentials

 

(2)Investigations:
A.For confirmation of diagnosis
1.Local part
• Discharge for CS
• Local part Xray
• Excision biopsy/wedge biopsy(small lesion)

Incision biopsy(large lesion)
2.LN
• Biopsy
B.For detection of distant Extension
Examination of oral cavity
• Examination of chest
• Chest Xray
• USG-WA

c.For diagnosis of Co morbidities/end organ damage

d.For Fitness

e.For follow up /prognosis

f.For planning

 

(3)Confirmatory diagnosis

 

(4)management
a.general management
• b.control of symptom
• c.control of co morbidities
• d.definitive management planning and execution

(5)FollowUP

 

 

Documents

preoperative per operative post operative

 

 

 

 

 

PAD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOLLOW UP SUMMARY

 

21.follow up summary

date SymptomsSymptom quantification signs CXR ECG/ETT ECHO ANGIO Glycemic profile Lipidprofile others

hhrids.com/HR date:
name: Age: sex: BMI: weight: Blood group:
Address: contact:
drug allergy: Rx status:
sufferings:
• LISTEN(open question)-hope and excitation
Chief complaints:
chest discomfort
palpitation
breathlessness
syncope
effort intolerance
others
family history
• CLARITY(closed question)-for diagnosis and grading the severity of symptoms
Quantification of dyspnoea NYHA functional classification of CHF Duke activity status index
• NARROW(focused question)differentials
• FITNESS(fixed questions)-previous operation/anaesthesia/post operative events/drugs/known allergy/co morbidities
Physical examination
• general
routine : anaemia cyanosis digital clubbing JVP oedema SPO2
pulse ( rate rhythm volume wall delay charecter )
BP MAP PP
source of infection:
site of surgery:
• systemic
inspection:
visible impulse
chest deformity
skin condition( scar mark pigmentation hair distribution )
palpation:
apex beat : site charecter
thrill: mitral tricuspid(left lower border of sternum) palpable P2 palpable A2
left parasternal heave
auscultation:
S1+S2 +extra HS +added sound + murmur ( site type charecter radiation )

• surgery related(site of surgery /any complication arose from offending pathology)
• specific(suitability of positioning during surgery)
INVESTIGATIONS:
depends on 1.type of surgery 2.patient(depending on natural history/incidence…sickle cell anaemia is investigated in afro americans, TB in south asians) 3.comorbidities
a. For confirmation of diagnosis
b. For treatment option work out
c. For fitness
d. For prognosis/followup of comorbid diseases
e.for detection of target organ damage
Diagnosis:
PLAN:
Risk scoring ASA euro score CRASH

 

 

PRE OPERATIVE PLANNING:
• record all relative informations
• optimise patient conditions
• choosing surgery with minimal risk and maximum benefit
• anticipate and plan for adverse events

PLAN:a. further investigations (Echo/markers/CT angiogram/angiogram/perfusion/lipid profile/diabetic profile)/b.clinical correlation neededc.follow up programmed.councelling and assurance
e treatment(life style modification/medical/interventional/surgical)
i. general management
ii.symptom alleviation
iii.control of comorbidities
iv.definitive management plan and execution
pre operative control of comorbidities
plan proper with estimation of predictive risk
back up plan with predictive risk
intra operative precaution
planning for post operative specific care
revised risk assessed after control of co morbidities
consent taken after explanation assurance and alternative option discussion with back up plan and predictive risk

follow up plan:
signature:

 

 

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