Nkwanta Surgical Outreach

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Nkwanta Surgical Outreach

Patient Screening Form

Outreach
Date
Unique ID
1

Registration

Patient identification

Unique ID
Date
Outreach event
Registered by (staff)
Full Name
Surname, Other names
Age (years)
Sex
MaleFemale
Phone Number
Occupation
Farmer / FisherTrader / Market vendorArtisan / Skilled workerCivil / Public servantStudentUnemployedOther (specify)
Level of Education
Education level
No formal educationPrimaryJunior High SchoolSenior High SchoolTertiary / UniversityVocational / TechnicalPost-graduate
Health Insurance
Insurance status
NHIS – activeNHIS – expiredPrivate insuranceNo insurance
2

Anthropometry

Measurements, vitals & labs

Weight (kg)
Height (cm)
BMI
Blood Pressure
Reading 1 — Systolic
Reading 1 — Diastolic
Reading 2 — Systolic
Reading 2 — Diastolic
Average BP
Interpretation
NormalElevatedStage 1 HypertensionStage 2 Hypertension
Other Vitals
Pulse (bpm)
SpO₂ (%)
RBS (mmol/L)
3

History / Triage

Complaint, medical history & labs

Complaint
Medical History
History of Hypertension
YesNo
History of Diabetes (DM)
YesNo
Asthma
YesNo
Sickle cell
YesNo
Previous surgery
YesNo
Previous surgery details
What surgery, when
Allergies
YesNo
Allergy details
Drugs, foods
Current medications
Social History
Smoking
YesNo
Alcohol
YesNo
Parity
e.g. P2+1
Review Labs
HB (g/dL)
WBC (×10⁹/L)
PLT (×10⁹/L)
Urea (mmol/L)
Creatinine (µmol/L)
Other lab — parameter
Result
Other lab — parameter
Result
4

Surgery

Surgical review

Surgical conditions
Thyroid mass / GoitreUterine fibroid(s)Inguinal herniaUmbilical herniaIncisional herniaFemoral herniaHaemorrhoidsLipomaSebaceous cystLymph node swellingBreast lump (benign)Other soft-tissue lumpOther (specify)
Other — specify
Notes / findings
Location, size, characteristics
Assessment
Fit for surgery
YesNo
Reason
5

Gynae

Gynaecological review

Fibroid
YesNo
Abnormal uterine bleeding
YesNo
Ovarian cyst
YesNo
Vulvovaginal mass
YesNo
Other
YesNo
Other — specify
Notes / findings
Assessment
Fit for surgery
YesNo
Reason
6

Anesthesia

Pre-anesthetic assessment

Have you ever had any anesthesia?
YesNo
Will you accept blood transfusion?
YesNo
General Condition
State of hydration
GoodFairObesePuffiness
Psychological
CalmApprehensiveUnstable
Colour
CyanosisPallorJaundice
Febrile
YesNo
Respiratory System
Any cough
YesNo
Distress
YesNo
Catarrh
YesNo
Chest auscultation
ClearInaudibleWheezingCracklesRhonchi
Air entering — Adequate
YesNo
Air entering — Reduced
YesNo
Respiratory rate (cpm)
Cardiovascular System
Chest pain
YesNo
Fatigability
YesNo
Palpitation
YesNo
B/P (mmHg)
Pulse (bpm)
Heart sounds (HS)
Airway Assessment
Airway assessment
Mallampati class, mouth opening
Neck movement mobile
YesNo
Any stiffness
YesNo
Any denture
NoYes — permanentYes — removable
ASA Physical Status Classification
Anaesthetic risk
ASA I — Normal healthy patientASA II — Mild systemic diseaseASA III — Severe systemic diseaseASA IV — Life-threatening diseaseASA V — Moribund patient
Outcome
Anesthesia assessment
PassFail
Remarks
7

Booking / Review

Decision & comments

Booked for surgery
YesNo
Surgery date
If not booked
CounselReferConservative treatment
Comment
Comment
8

Management Sheet

Operative & post-operative record

Preop list
Pre-operative checklist / orders
Intraop Findings
Time started
Time ended
EBL (estimated blood loss, mL)
Intraop findings
Post op plan
Post Op
Vitals
BP, pulse, SpO₂, temperature
Notes
Post-operative complications (tick all that apply)
NoneWound infection / SSIWound dehiscenceHaematoma / SeromaBleeding requiring interventionRecurrent laryngeal nerve injuryHypocalcaemia (post-thyroidectomy)Urinary retentionDeep vein thrombosis (DVT)Pulmonary embolismPneumonia / Respiratory complicationAnaesthetic complicationReturn to theatreOther
Discharged
YesNo
State and plan at discharge