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Esic Joka (Anaethesia) Esanjeevaniopd: General Examination & Chief Complaints

1. The patient presented with a history of diabetes, hypertension, hypercholesterolemia, and neuropathy. Laboratory tests showed elevated fasting blood sugar, post-prandial blood sugar, blood pressure, and cholesterol levels. 2. The provisional diagnoses were diabetes mellitus, hypertension, and hypercholesterolemia. Medications including amlodipine, vildagliptin, atorvastatin, methyLCobalamin, and pantoprazole were prescribed. 3. The patient was advised to continue a diabetic diet, salt restricted diet, monitor blood pressure, and repeat laboratory tests in one month. Further consultations were recommended by reviewing in the medicine department.

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Sourav Biswas
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173 views1 page

Esic Joka (Anaethesia) Esanjeevaniopd: General Examination & Chief Complaints

1. The patient presented with a history of diabetes, hypertension, hypercholesterolemia, and neuropathy. Laboratory tests showed elevated fasting blood sugar, post-prandial blood sugar, blood pressure, and cholesterol levels. 2. The provisional diagnoses were diabetes mellitus, hypertension, and hypercholesterolemia. Medications including amlodipine, vildagliptin, atorvastatin, methyLCobalamin, and pantoprazole were prescribed. 3. The patient was advised to continue a diabetic diet, salt restricted diet, monitor blood pressure, and repeat laboratory tests in one month. Further consultations were recommended by reviewing in the medicine department.

Uploaded by

Sourav Biswas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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ESIC Joka (Anaethesia) eSanjeevaniOPD

ESI PGIMSR ESI Hospital, Manicktala,KOLKATA


West Bengal,000000

Patient ID: 1902313229644848 Date: 05 Feb 2022, 12:30 PM


Patient: SANJAY DAS , 43 YEARS / MALE Consultation ID: 12685918
Mobile: 9339627837 Speciality: Anaesthesia
Address: COOPERS CAMP 5 NO WARD, NADIA, WEST
BENGAL
General Examination & Chief Complaints:
History of Diabetes - Yes
History of Hypertension - Yes
Fbs-206 ppbs-267 BP-160/100 cholesterol-279 Patient currently on T. Glyciphage G1 1g BD and T. Telma 40 OD

Provisional Diagnosis:
Diabetes mellitus
Hypertension
Hypercholesterolemia
Neuropathy
Epigastric pain

Rx:
Sl. No. Medicine Frequency Dose Type Duration
1 Amlodipine (as amlodipine besilate) 5 mg oral tablet OD 1 tablet(s)/capsule(s) 4 Week
2 Vildagliptin 50 mg oral tablet OD 1 tablet(s)/capsule(s) 4 Week
3 Atorvastatin 10 mg prolonged-release oral tablet HS 1 tablet(s)/capsule(s) 4 Week
4 MethyLCobalamin 750 mcg and pregabalin 75 mg oral tablet HS 1 tablet(s)/capsule(s) 4 Week
5 Pantoprazole sodium 40 mg oral tablet OD 1 tablet(s)/capsule(s) 4 Week

Continue glyciphage gp1 and telma 40 as before. Repeat fbs ppbs after 1month take vildagliptin 50 before lunch. T
amlodipine 5 at 7am
Advice:
Case consulted in discussion with HoD. Diabetic diet and salt restricted diet. Continue medications as prescribed. Repeat the
fbs and ppbs and review with report. Measure BP and maintain chart. For further consultations review in medicine pod

WBMC 76101
Dr. TRISHA CHOWDHURY
ESI PGIMSR & ESIC Medical College, Joka
Kolkata, West bengal

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