Request for Admission

Admitted Under

Dr.Sumit Singh

Type of Admission:	First Time
Reason for Admission :	Emergency

Referral By:
Patient Identification Band tied:	Yes

Created & Updated

By :Dr.Sumit Singh

At : 2024-08-23 23:03:19

 

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 ?:	No
Have you visited a health care facility in the past two weeks?:	No

Created & Updated

By :Dr.Sumit Singh

At : September 13, 2024 / 12:47:58 PM

Medical Surgical History

Medical Assessment	Status
Diabetes	Cured

Allergies	Category
Chicken nuggets	Food

Information Obtained from

Family-Other

Addiction

Alcohol:
Smoking:

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-13

Vulnerability Assessment

Level of Consciousness :	UnConscious
Dependency :
Mode of Movement :
Vulnerability Assessment/ Triage :	Normal_care
Pain Assessment :	/10
Pain Location :

Fall Risk

Low fall risk:	Yes
implement low fall risk interventions per protocol:	Yes
Complete paralysis or completely immobilized:	No

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-13

 

Vitals

BMI	404.52
SPo2	240
RBS	100
Temperature	100
Pulse	120
Blood Pressure:	145/120

Created & Updated

By :Dr.Sumit Singh

At : September 13, 2024 / 12:54:28 PM

Medical Assessment

Fever:	Yes	2 Day
Loss of Smell:	Yes	2 Day
Diarrhoea:	Yes	2 Day
Facial Deformity:	Yes	2 Day
Cough:	Yes	2 Day
Loss of Taste:	Yes	2 Day
Weakness:	Yes	2 Day
Breathlessness:	Yes
Shivering:	Yes
Power Loss in Limbs:	Yes
Other Symptoms :	none

Created & Updated

By :Dr.Sumit Singh

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:	No
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 :	Yes
Does the patient have any parenteral tube feeding:	No
Food Pattern Followed :	Vegetarian
Appetite	Good

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-13

General Consent

General Consent Signed

Prescription

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

Level of Consciousness :	UnConscious
Vulnerability Assessment :	Normal_care
Pain Assessment :
Pain Location :

Vitals

SPo2(%)	RBS(mg/dl)	Temp(C*)	Pulse(Min)	BP(mmHg)
240	100	100	120	145/120

BMI Result

24.38

Chief Complain

Fever:		2 Day
Loss of Smell:		2 Day
Diarrhoea:		2 Day
Facial Deformity:		2 Day
Cough:		2 Day
Loss of Taste:		2 Day
Weakness:		2 Day
Breathlessness:
Shivering:
Power Loss in Limbs:
Other Symptoms :	none

Significant findings :	null
Nutritional diagnosis	Normal
Provisional diagnosis	N96
Proposed Surgery:	Flap cover

Investigation

Date Time	Investigation	Result	Evidence (Upload)
September 20, 2024 / 05:15:22 PM	MRI -SPINE-Thoracic
September 20, 2024 / 05:16:26 PM	3 methoxytyramine (Plasma)

Rx

Drug & Dose	Route	Note	Frequency	Duration
UDILIV - 300-300 URSODEOXYCHOLIC ACID TABLET	Orally	After meal	BID/b.i.d. (twice a day)	5 Days