Appendix C — Sample Case Sheets and Examination Proformas
This appendix gives practical templates for everyday use. They follow the same sequence taught throughout this manual, from history to management plan. Adapt the wording to your own patient, and add local letterhead as needed.
C.1 General Anorectal Case Sheet
Patient Details
Name: ________________________________________
Age / Sex: ________________________________________
Date: ________________________________________
Occupation: ________________________________________
Contact number: ________________________________________
Presenting Complaint
Main complaint, with duration: ________________________________________
Associated symptoms: ________________________________________
History of Presenting Complaint (follow Chapter 2)
Bleeding: colour, amount, timing: ________________________________________
Pain: site, character, timing, relation to defecation: ________________________________________
Swelling or lump: onset, whether it reduces: ________________________________________
Discharge: type, amount: ________________________________________
Change in bowel habit: ________________________________________
Prolapse: frequency, whether it reduces spontaneously: ________________________________________
Bowel habit and stool consistency: ________________________________________
Red Flag Screen
Unexplained weight loss ☐
Persistent change in bowel habit ☐
Anaemia or unexplained fatigue ☐
Age over 50 with new symptoms ☐
Family history of colorectal cancer ☐
Past History
Previous anorectal surgery: ________________________________________
Obstetric history (if relevant): ________________________________________
Relevant medical conditions (diabetes, IBD, HIV): ________________________________________
Medications: ________________________________________
Examination (follow Chapters 3 to 6)
General examination: pallor, weight, abdomen, groin nodes: ________________________________________
Inspection: findings at rest and on straining: ________________________________________
Digital rectal examination: tone, tenderness, mass, blood on glove: ________________________________________
Proctoscopy / sigmoidoscopy findings: ________________________________________
Provisional Diagnosis: ____________________________________________________________
Investigations Planned: ____________________________________________________________
Management Plan: ____________________________________________________________
Follow-Up Arranged: ____________________________________________________________
C.2 Digital Rectal Examination — Quick Findings Template
Resting tone (normal / reduced / increased): ________________________________________
Squeeze tone (normal / reduced): ________________________________________
Tenderness (present / absent), site: ________________________________________
Mass (present / absent), position, mobility: ________________________________________
Sphincter defect (present / absent), position: ________________________________________
Prostate (if male): size, consistency: ________________________________________
Blood on glove (present / absent): ________________________________________
Stool in rectum (present / absent), consistency: ________________________________________
C.3 Sample Operative Note — MOLIS
Date: ________________________________________
Indication: ________________________________________
Anaesthesia: ________________________________________
Position: ________________________________________
Operative site (o'clock position): ________________________________________
Findings: ________________________________________
Internal sphincter delivered to wound surface (yes / no): ________________________________________
Corrugator cutis ani identified and preserved (yes / no): ________________________________________
Depth of division: ________________________________________
Haemostasis: ________________________________________
Estimated blood loss: ________________________________________
Postoperative instructions: ________________________________________
C.4 Postoperative Follow-Up Proforma
Date of review: ________________________________________
Days since surgery: ________________________________________
Wound (healing / not healing), any discharge: ________________________________________
Pain (resolved / ongoing): ________________________________________
Bowel habit: ________________________________________
Continence (normal / any change, specify): ________________________________________
Further follow-up needed (yes / no); if yes, date: ________________________________________