General Surgery Clinical Case Proforma

For Ward Presentation — Department of General Surgery

| Date:

1. Identification & Presenter Details

Patient Name

Age / Sex

IPD / Bed No.

Occupation

Address

Date of Admission

Presenting Student & Roll No.

History given by

Patient Attendant

2. Chief Complaints

Tick all that apply (patients often present with more than one). Fill site, side and duration for each selected.

✓	Chief Complaint	Side	Site	Duration (since)
	Abdominal pain
	Swelling / lump
	Vomiting
	Constipation / altered bowel habit
	Abdominal distension
	Non-healing wound / ulcer
	Rectal bleeding
	Yellowish discolouration of eyes (jaundice)
	Trauma-related complaint
	Breast lump
	Other:

3. History of Present Illness

Mode of Onset

Character of Pain / Key Symptom — SOCRATES

To be filled whenever pain is a chief complaint (e.g. abdominal pain, lump pain).

S — Site
O — Onset
C — Character
R — Radiation
A — Associated symptoms
T — Timing
E — Exacerbating / relieving factors
S — Severity (0–10)

4. Past, Personal, Family & Treatment History

5. General Physical Examination

Build

Nutrition

Consciousness

Vitals

PR (/min)

BP (mmHg)

RR (/min)

Temp

SpO2 (%)

RBS

GCS

6. Local Examination — Region:

A. Per Abdomen — Inspection

B. Per Abdomen — Palpation

C. Percussion & Auscultation

Percussion
Auscultation

D. Examination of Swelling / Lump (if applicable)

To be filled whenever Swelling/Lump is a chief complaint — site, size, shape, surface, edge, consistency, fluctuation, transillumination, reducibility, and regional lymph nodes.

Site & Size
Shape & Surface
Edge / Margin
Consistency
Fluctuation / Transillumination
Reducibility / Cough impulse
Regional lymph nodes

E. Digital Rectal Examination / Hernial Orifices (if indicated)

7. Systemic Examination

8. Investigations

✓	Investigation	Findings
	Ultrasound abdomen / pelvis
	CT abdomen
	Upper GI endoscopy
	Colonoscopy
	Hb / TLC / platelet count
	Blood grouping & typing
	Liver function test
	Renal function test
	Serum amylase / lipase
	Coagulation profile
	Tumor markers
	Other:

9. Diagnosis

Provisional Diagnosis

Differential Diagnosis

10. Treatment Plan

11. Summary

Auto-generated from ticks & entries above, in the fixed order of the sections — edit freely before presenting.

Presenting Student's Signature

Countersigned by Faculty / Resident

General Surgery Clinical Case Proforma — for teaching purpose · not a legal medical record

Sign	Absent	Present	Details (site / grade)
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema

System	Normal	Abnormal	Details
Cardiovascular System
Respiratory System
Central Nervous System