Request for Admission

Admitted Under

Dr.Sumit Singh

Type of Admission:	First Time
Reason for Admission :	Treatment & Observation

Referral By:	SANTUSHTI HOSPITAL PVT LTD
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 ?:	Yes
Have you visited a health care facility in the past two weeks?:	No

Created & Updated

By :Dr.Sumit Singh

At : September 14, 2024 / 01:16:47 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 : 2024-09-14

Vulnerability Assessment

Level of Consciousness :	Conscious
Dependency :
Mode of Movement :	Self
Vulnerability Assessment/ Triage :	Normal_care
Pain Assessment :	7/10
Pain Location :	Stomach

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-14

 

Vitals

BMI	404.52
SPo2	45
RBS	112
Temperature	122
Pulse	112
Blood Pressure:	12/11

Created & Updated

By :Dr.Sumit Singh

At : September 14, 2024 / 01:18:02 PM

Medical Assessment

Fever:	Yes	2 days
Cough:	Yes	1 week
Sore Throat :	Yes	4 days
Slurred Voice:	Yes

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-14

Nutritional Screening

Does the patient have any weight loss/ Weight gain?:	No
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 :Dr.Sumit Singh

At : 2024-09-14

General Consent

General Consent Signed

Prescription

Type of Admission::	First Time
Reason for Admission :	Treatment & Observation

Level of Consciousness :	Conscious
Vulnerability Assessment :	Normal_care
Pain Assessment :	7
Pain Location :	Stomach

Vitals

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

BMI Result

24.38

Chief Complain

Fever:		2 days
Cough:		1 week
Sore Throat :		4 days
Slurred Voice:
Other Symptoms :

Investigation

Date Time	Investigation	Result	Evidence (Upload)
September 14, 2024 / 01:34:13 PM	CT + 3D -PELVIS-Sacroliac Joints
September 14, 2024 / 01:34:29 PM	COMPLETE BLOOD COUNT (CBC)

Rx

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

Plan Of Care

Treatment facility option

Dr.Sumit Singh (MBBS, MD)	September 14, 2024 / 01:36:13 PM