National Programme for Control of Blindness
Cataract Operation Register Form District Hospital
Registration No.:
Name of Patient:
Address:
Age/Sex:
Mob:
Provisional Diagnosis:
RE :
LE :
General Examination:
S/MO SDH/RH/PHC
K/c of - Asthma / Hypertension/DM/TB/Allergy/IHD
Pulse
BP
Resp
CVS
P/A
G.C.
Gen Examination:
Preoperative Investigation:
Sugar
Urine:
- Albumin
- Hb%
Pallor
Oedema
Xylocaine Sesitivity Test:
A-SCAN
IOL POWER
Ocular Examination
Lid
Conjunctiva
Cornea
AC
Iris
Pupil
Lens
Ocular movement
VIA
RE
LE
Rx (Advised)
with PH
with PH
-Mosi-D Eye drop 4 times
-Tab cipro 500mg BDx5d
-Tab Rantac 150mg
-Tab PCM 500mg
Tags:
Consent Form