Request for Consultation

Admitted Under

Dr.Sumit Singh

Type of Admission:	First Time
Reason for Admission :	Emergency

Referral By:	XYZ HEALTHCARE PVT. LTD
Patient Identification Band tied:	Yes
Patient Made aware of surroundings and safety measures:	Yes

Created & Updated

By :Abhay Kumar

At : 2024-08-23 06:27:03

 

Covid 19 Checklist

Do you have symptoms such as fever, cough, sneezing, sore throat, fatigue, sense of smell, changes in taste, and body aches?:	Yes
Do you have difficulty of breathing?:	Yes
Have you travelled outside the country in the last 30 days?:	Yes
Have you traveled to other cities in India in 15 days?:	Yes
Were you a Covid-19 positive patient in the last two weeks? or suspect in a case of covid-19 ?:	Yes
Have you visited a health care facility in the past two weeks?:	Yes

Created & Updated

By :Abhay Kumar

At : September 13, 2024 / 01:26:23 PM

MLC

MLC No :	65858

Created & Updated

By :Abhay Kumar

At : 2024-08-23 06:27:03

 

Trauma Checklist

Immediately after primary & secondary surveys

Is Further Airway Intervention Needed? :	Yes
Is There A Tension Pneumo-Haemothorax ? :	Yes, Chest Drain Placed
IS The Pulse and Fluids Started ? :	Yes
Large-bore IV placed and fluids started :	Yes
Full Survey For (and control of)External bleeding, Including:	Scalp  ,Perineum  ,
Assessed For Pelvic Fracture by :	Exam
Assessed For Internal Bleeding By:	Exam
Is Spinal Immobilization Needed? :	Yes,Done
Neurovascular Status of all 4 limbs Checked? :	Yes
IS the patient Hypothermic? :	Yes, Warming
Does the Patient Need(if no contraindication) :	Urinary Catheter, Nasogastric Tube, chest drain, None Indicated,
Has the Patient been Given :	Tetanus Vaccine, Analgesics, , None Indicated,
Have All tests and imaging been Reviewed :	Yes
Which serial Examinations Are Needed:	None
Plan of care discussed with :	Patient/Family, Receiving Unit,  Primary team,  Other_Specialists,
Relevant Trauma Chart or Form Comleted? :	Patient/Family

Created & Updated

By :Abhay Kumar

At : 2024-09-13

 

Medical Surgical History

Medical Assessment	Status
Diabetes	Active

Allergies	Category

Information Obtained from

Family-Other

Addiction

Alcohol:
Smoking:

Created & Updated

By :Abhay Kumar

At : 2024-09-13

Vulnerability Assessment

Level of Consciousness :	Conscious
Dependency :	Independent
Mode of Movement :	Ambulatory
Vulnerability Assessment/ Triage :	Urgent_Care
Pain Assessment :	1/10
Pain Location :	Chest

Created & Updated

By :Abhay Kumar

At : 2024-09-13

 

Vitals

BMI	33.92
SPo2	45
RBS	112
Temperature	122
Pulse	2
Blood Pressure:	12/11

Created & Updated

By :Abhay Kumar

At : September 13, 2024 / 02:09:13 PM

Medical Assessment

Fever:	Yes	2 days
Loss of Smell:	Yes	2 days
Diarrhoea:	Yes	2 days
Facial Deformity:	Yes	2 days
Cough:	Yes	1 week
Loss of Taste:	Yes	2 days
Weakness:	Yes	2 days
Breathlessness:	Yes	2 days
Shivering:	Yes	2 days
Power Loss in Limbs:	Yes	2 days
Sore Throat :	Yes	4 days
Vomitting :	Yes	25 days
Slurred Voice:	Yes
Nausea:	Yes
Other Symptoms :	no

Created & Updated

By :Abhay Kumar

At : 2024-09-13

Nutritional Screening

Does the patient have any weight loss/ Weight gain?:	Yes
Does the patient appear emaciated or BMI is Below <18.5 ?:	Yes
Does the patient look Obese or BMI is above >30:	Yes
Does the patient have any GL Symptoms like Constipation, Nausea, Diarrhea, Anorexia, Vomiting, chewing/swallowing difficulty affecting oral intake in last 2 weeks:	No
Does the patient have any enteral tube feeding :	No
Does the patient have any parenteral tube feeding:	Yes
Food Pattern Followed :	Vegetarian
Appetite	Fair

Created & Updated

By :Abhay Kumar

At : 2024-09-13

General Consent

General Consent Signed

Prescription

Type of Admission::	First Time
Reason for Admission :	Emergency

Level of Consciousness :	Conscious
Vulnerability Assessment :	Urgent_Care
Pain Assessment :	1
Pain Location :	Chest

Vitals

SPo2(%)	RBS(mg/dl)	Temp(C*)	Pulse(Min)	BP(mmHg)
45	112	122	2	12/11

BMI Result

33.92

Chief Complain

Fever:		2 days
Loss of Smell:		2 days
Diarrhoea:		2 days
Facial Deformity:		2 days
Cough:		1 week
Loss of Taste:		2 days
Weakness:		2 days
Breathlessness:		2 days
Shivering:		2 days
Power Loss in Limbs:		2 days
Sore Throat :		4 days
Vomitting :		25 days
Slurred Voice:
Nausea:
Other Symptoms :	no

Investigation

Date Time	Investigation	Result	Evidence (Upload)

Rx

Drug & Dose	Route	Note	Frequency	Duration