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Examined By Doctor
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Diagnosis :
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Advice :
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Medications
| MEDICATION GENERIC |
WAY |
FREQUENCY |
DURATION |
DURATION TYPE |
QUANTITY |
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Investigations, USS and X-Rays
| INVESTIGATION ID |
INVESTIGATION |
STATUS |
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Vitals :
Blood Pressure (Systolic) :
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Blood Pressure (Diastolic) :
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Body Temparature (Celcius) :
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Body Temparature (Farenhite) :
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Respiratory Rate :
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/min
Pulse Rate :
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/min
O2 Saturation :
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%
Height :
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Weight :
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kg
BMI :
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Ideal Weight :
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CVS Examination :
Surgical scars :
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Deformalities :
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Heaving :
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Palpable Heart Sound :
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Heart Murmurs
Systolic :
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/min
Diastolic :
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/min
RS Examination :
Chest Deformalities :
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Chest Asymetry :
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Surgical Scars :
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ICR :
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SCR :
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Chest Expansion :
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Vocal Fermitus :
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Bronchial Sounds
Air Entry :
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Rhonchi :
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Crepitations :
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Abdominal Examination :
Distension :
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Assymetry :
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Surgical Scars :
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Visible Lump :
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Palpable Lump :
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Tenderness :
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Precussion :
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Bowl Sounds :
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Neurological Examination :
GCS :
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Confusion :
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Speech Impairment :
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Locomotor Examination :
Asymetry :
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Deformity :
Genu valgus :
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Genu varus :
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Swelling :
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Scars :
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Muscle wasting :
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Gait (walking) :
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Foot drop :
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Warmth :
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Patella Tap :
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Joint Margine tenderness :
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Crepitation :
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KJ Flexion/Extension (Passive) :
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Collateral Ligament :
Lateral :
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Medial :
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Crusiate Ligament :
Anterior :
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Postterior :
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Menitus :
Lateral :
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Medial :
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Diabetic Foot Record :
FOOT / EX :
Left Foot
1. Lying Symetrical :
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2. Corns and Callus :
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3. Oedema :
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4. Errythema :
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5. Fungal Infection :
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6. Warmth :
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7. Cold :
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8. Pain :
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Right Foot
1. Lying Symetrical :
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2. Corns and Callus :
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3. Oedema :
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4. Errythema :
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5. Fungal Infection :
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6. Warmth :
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7. Cold :
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8. Pain :
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GAIT :
Left Foot
1. Limping :
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2. Waddeling :
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GAIT :
Left Foot
1. Limping :
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2. Waddeling :
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DEFORMITIES :
Left Foot
1. Clawed Toes :
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2. Pes Cavus :
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3. Flatten Arches Medial :
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4. Flatten Arches Lateral :
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5. Previous Surgery :
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Right Foot
1. Clawed Toes :
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2. Pes Cavus :
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3. Flatten Arches Medial :
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4. Flatten Arches Lateral :
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5. Previous Surgery :
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NAILS :
Left Foot
1. Uncut And Overgrown :
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2. In-Growing :
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3. Atrophied :
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4. Hypertrophied :
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5. Subungual Cerotosis :
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6. Paronychia :
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Right Foot
1. Uncut And Overgrown :
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2. In-Growing :
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3. Atrophied :
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4. Hypertrophied :
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5. Subungual Cerotosis :
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6. Paronychia :
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WEB SPACES :
Left Foot
1. Maceration :
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2. Fungal Infection :
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Right Foot
1. Maceration :
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2. Fungal Infection :
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JOINTS LIMITED JOINT MOBILITY :
Left Foot
1. Ankle :
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2. First Toe :
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3. Other Toes :
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Right Foot
1. Ankle :
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2. First Toe :
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3. Other Toes :
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SKIN :
Left Foot
1. Dry :
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2. Discoloured :
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3. Furuncels :
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4. Loss Of Hair :
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Right Foot
1. Dry :
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2. Discoloured :
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3. Furuncels :
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4. Loss Of Hair :
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PULSES :
Left Foot
1. Femoral :
2. Popliteal :
3. Post Libial :
4. D Pedis :
Right Foot
1. Femoral :
2. Popliteal :
3. Post Libial :
4. D Pedis :
LAB TSETING FOR NEUROPATHY :
Left Foot
1. Vbration Sense by Tuning Fork :
2. Sensation of monofilament :
3. Heat and Cold Sensation :
Right Foot
1. Vbration Sense by Tuning Fork :
2. Sensation of monofilament :
3. Heat and Cold Sensation :
EXAMINATION OF FOOT ULCER :
Left Foot
1. History of Trauma :
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2. Shoe Bite :
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3. Injury :
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4. Walking Bear foot :
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5. Walking Weight bearing :
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Right Foot
1. History of Trauma :
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2. Shoe Bite :
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3. Injury :
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4. Walking Bear foot :
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5. Walking Weight bearing :
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ULCER :
Left Foot
1. Grenulation :
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2. Peri ulcer Edema :
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3. Slough :
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4. Exposed Tendon :
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5. Exposed Bones :
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6. Foot Edema :
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7. Limb Edema :
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8. Dialated Limb veins :
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9. Neurotic Tissue :
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Right Foot
1. Grenulation :
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2. Peri ulcer Edema :
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3. Slough :
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4. Exposed Tendon :
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5. Exposed Bones :
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6. Foot Edema :
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7. Limb Edema :
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8. Dialated Limb veins :
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9. Neurotic Tissue :
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