Request for Consultation

Admitted Under

Dr.Sumit Singh

Type of Admission:	Continuation of Treatment
Reason for Admission :	Treatment & Observation

Referral By:	SHARDA HOSPITAL AND NEURO TRAUMA CENTRE
Patient Identification Band tied:	Yes
Patient Made aware of surroundings and safety measures:	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?:	No
Do you have difficulty of breathing?:	Yes
Have you travelled outside the country in the last 30 days?:	No
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 :Dr.Sumit Singh

At : September 20, 2024 / 04:55:21 PM

Medical Surgical History

Medical Assessment	Status
Diabetes	Cured

Allergies	Category
Chicken nuggets	Food

Information Obtained from

Patient

Addiction

Alcohol:

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-20

Vulnerability Assessment

Level of Consciousness :	SemiConscious
Dependency :	Completely Dependent
Mode of Movement :	Self
Vulnerability Assessment/ Triage :	Urgent_Care
Pain Assessment :	/10
Pain Location :

Fall Risk

High fall risk:	Yes
History of more than one fall within 6 months before admission:	Yes
Patient has experienced a fall during the hospitalization:	Yes
Patient is deemed high fall-risk per protocol such as seizure precaution:	Yes

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-20

 

Vitals

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

Created & Updated

By :Dr.Sumit Singh

At : September 20, 2024 / 04:56:19 PM

Medical Assessment

Fever:	Yes	2 days
Cough:	Yes	1 week
Sore Throat :	Yes	4 days
Physical Injury :	Yes	2 days
Other Symptoms :	no

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-20

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:	Yes
Does the patient have any enteral tube feeding :	Yes
Does the patient have any parenteral tube feeding:	Yes
Food Pattern Followed :	Eggetarian
Appetite

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-20

General Consent

General Consent Signed

Prescription

Type of Admission::	Continuation of Treatment
Reason for Admission :	Treatment & Observation

Level of Consciousness :	SemiConscious
Vulnerability Assessment :	Urgent_Care
Pain Assessment :
Pain Location :

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
Physical Injury :		2 days
Other Symptoms :	no

Investigation

Date Time	Investigation	Result	Evidence (Upload)

Rx

Drug & Dose	Route	Note	Frequency	Duration