|
|
| MRD / Regn No. |
: 20180000258 |
Date |
: 30/06/2026 |
| Patient Name |
: Jijo George |
Age & Gender |
: 53 Yrs. / Male |
| Contact No. |
: 9962531530 |
UHID |
: |
| Ht / Wt / BMI |
: 177 / 75.9 / 24.23 |
BP S / BP D |
: 113 / 76 |
| Allergies |
: NKA |
Referred By |
: |
| |
|
| Problem
List |
: |
TYPE 2 DM (09/Apr/2018) | DYSLIPIDEMIA (09/Apr/2018) | INFLAMMATORY MYOCARDITIS (01/Aug/2022) | COMPLETE HEART BLOCK (01/Aug/2022) | SHOULDER DISLOCATION (02/Jan/2023) | DYSSOMNIA (16/Nov/2023) | NAFLD (24/Jun/2024) | |
|
Subjective |
: |
SLEEP IMPROVED,HAS RESUMED EXERCISE,NOCTURIA IMPROVED,MILD INTENTION TREMORS |
|
Objective |
: |
NONE,INCREASED PVR |
|
Analysis |
: |
T2DM WELL CONTROLLED,VITAMIN D INSUFFICIENCY,INFLAMMATORY MYOCARDITIS WITH COMPLETE HEART BLOCK,INCREASED FIB4 / NAFLD SCORE,S1F1 NAFLD,R/O BPH,R/O FAMILIAL TREMOR,VITAMIN B12 DEFICIENCY |
|
Plan |
: |
CONTINUE CURRENT MEDICATIONS,SEE ME IN 2 MONTHS WITH TESTING,MAY NEED GLP1RA |
|
| Salient Investigations |
: |
FASTING PLASMA GLUCOSE (FPG): 131 mg/dL | GLYCOSYLATED HEMOGLOBIN (HBA1C): 7 % | POST PRANDIAL GLUCOSE (2HPP): 149 mg/dL | |
|
S# |
Generic (Trade) Name |
Route |
Dosage |
Usage |
Duration |
|
1 |
CHOLECALCIFEROL 2000 IU
D RISE 2000 IU
Medicine For VITAMIN D |
PO |
0-0-1 |
AT BEDTIME
|
TILL NEXT VISIT |
| TAKE AT BEDTIME | |
|
2 |
ROSUVASTATIN 10 MG
CRESTOR 10 MG
Medicine For CHOLESTEROL |
PO |
0-0-1 |
AT BEDTIME
|
TILL NEXT VISIT |
| MAY | |
|
3 |
TABLET DAPAGLIFLOZIN 10 MG PIOGLITAZONE 15 MG
UDAPA PRO
Medicine For DIABETES MASLD |
PO |
1-0-0 |
BEFORE FOOD
|
TILL NEXT VISIT |
| MAY CAUSE GU INFECTIONS AND FEET SWELLING | |
|
4 |
INJECTION METHYCOBALAMIN 1 MG (INJECTION)
RENERVE PLUS 1 MG (INJECTION)
Medicine For VITAMIN B12 DEFICIENCY |
IM |
ONCE A MONTH |
TO BE ADMINISTERED BY A HCP ONLY
|
THREE MONTHS |
| TO BE ADMINISTERED BY A MEDICAL PRACTITIONER OR NURSE ONLY | |
|
| |
|
|
|
| Refill :
0 / Substitution: |
|
|
| Education |
: |
| Next Visit |
: 28/Aug/2026 |
| Tests Suggested For Next Visit |
: FBS 2HPP HBA1C |
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