MEDICAL REPORTPatient Information Name: DOB: / / Gender:Department : Room No:2 Ref.No:Treating Doctor: Date of Admission: Date of discharge:/ History of Present IllnessChief Complaint (s): Present illness: Past Medical History: Past Surgical History: Family History: Allergy Vital signsBP: mm Hg Pulse: PR: Temp: SpO2: Weight: Height: BMI: Physical Exam General Condition: HEENT - TMH Cardiovascular - Respiratory – Abdomen C.N.S - Muscle Skeletal- Genito Urinary- Investigation & ProcedureLaboratory -WBC : GRA :-negative-negativeRadiology - Lots of water & gas in the bowl Provisional Diagnosis Treatment & Medication: Management Plan/ Recommendation Attending Doctor
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