Year 4 Surgery Logbook
Name:

Surgeon:
Elective

 If Extramural or IDE, enter identifying information here:
Elective End Week: Date Patient Seen:    mm/dd/yy 
Patient's Age:
Newborn (0-11 mo)
Pediatrics (1-12 years)
Adolescent (13-17 years)
Adult (18-64 years)
Geriatric (65+ years)

Patient's Gender:

Location: 

Chief Complaint:
*None fatigue painful limb
abdominal distention fever/chills paralysis
abdominal mass flank pain pelvic mass
abdominal pain fractures/dislocation/joint injuries renal failure acute or chronic
abnormal liver function tests gait disturbances rhinosinusitis
abnormality of the white blood cells gastroesophageal reflux scar revision
acute illness in an infant/child gastrointestinal bleeding scrotal mass/pain
anemia head injury/brain death/transplant donation seizures
back pain headache shock/hypotension
bleeding tendency/bruising hearing loss/deafness skin lesions
breast disorders hematemesis sleep disturbances
burns hematuria sore throat
cardiac arrest/respiratory arrest hemoptysis spinal injuries
chest discomfort/Angina pectori hemorrhoids/rectal mass splenamegaly
colon polyps hernia syncope
colonoscopy/routine screening impaired consciousness tinnitus
dementia/memory disturbances Inflammatory Bowel Disease torticollis
depressed newborn jaundice transplant recipient
diarrhea/constipation joint pain non-traumatic trauma
difficulty swallowing limb pain in lower extremity in children urinary disorder/incontinence/ incomplete emptying/frequency
dizziness/vertigo lymph adenopathy vomiting/nausea
dysphonia/hoarsness mammogram/routine screening weakness/paralysis
dyspnea/breathlessness mouth/oral disorders weight gain/obesity
ear pain murmur/abnormal heart tones weight loss
edema/ascites/anasarca neck mass/goiter wheezing/coughing
electrolyte disorder numbness/tingling/paresthesia    
falls occult blood in stool    

Surgeries:

 

 

Jean Afflerbach, Web Master
Revised: September 06, 2012