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| MRD / Regn No. |
: 20250000493 |
Date |
: 08/07/2026 |
| Patient Name |
: Pushpa Garai |
Age & Gender |
: 59 Yrs. / Female |
| Contact No. |
: 9647744475 |
UHID |
: |
| Ht / Wt / BMI |
: |
BP S / BP D |
: |
| Allergies |
: NKA |
Referred By |
: |
| |
|
| Problem
List |
: |
TYPE 2 DM (30/Jun/2010) | ATHEROSCLEROTIC CARDIOVASCULAR DISEASE (30/Jun/2025) | HEART FAILURE STAGE B (02/Jul/2025) | ANEMIA MICROCYTIC HYPOCHORMIC (02/Jul/2025) | A1G2 DKD (02/Jul/2025) | VITAMIN D INSUFFICIENCY (02/Jul/2025) | |
|
Subjective |
: |
TYPE 2 DM FOR 15 YEARS,ASCVD FOR 6 YEARS,HAS BURNING IN FEET,HAS KNEE PAIN |
|
Objective |
: |
TENDERNESS IN THE MEDIAL ASPECK OF THE KNEE |
|
Analysis |
: |
TYPE 2 DM,ATHEROSCLEROTIC CARDIOVASCULAR DISEASE,HEART FAILURE STAGE B,VITAMIN D INSUFFICEINCY,DR CHANGES IN THE FUNDUS,DISTAL SENSORY NEUROPATHY,OSTEOPENIA |
|
Plan |
: |
ADD SEMAGLUTIDE 0.5 MG,INCREASE INSULIN 12 UNITS,SEE ME IN 1 MONTH |
|
| Salient Investigations |
: |
VITAMIN D (25 OH): 45.3 ng/mL | NT PROBNP : 144 pg/mL | FREE T4 : 1.25 ng/dL | TSH : 1.450 mIU/L | BUN BLOOD UREA NITROGEN: 28.8 mg/dL | UREA: 62 mg/dL | HIGH SENSITIVE C REACTIVE PROTEIN: 0.69 mg/L | A\G RATIO: 1.54 g/dl | ALBUMIN (SERUM): 4.04 g/dL | ALKALINE PHOSPHOTASE: 124 IU/L | DIRECT BILIRUBIN: 0.32 mg/dl | GAMMA GLUTAMYL TRANSFERASE (GGT): 15 U/L | GLOBULIN: 2.63 g/dl | INDIRECT BILIRUBIN: 0.37 | SGOT (AST): 17 U/L | SGPT (ALT): 15 IU/L | TOTAL BILIRUBIN: 0.69 mg/dL | TOTAL PROTEIN: 6.67 g/dl | MICROALBUMIN CREATININE RATIO: 4.13 mcg/mg | ANTI CYCLIC CITRULLINATED PEPTIDE (ANTI CCP) ANTIBODY: <0.5 u/mL | RA FACTOR: 9.25 IU/mL | CRP C REACTIVE PROTEIN: 3.33 mg/dL | HEMOGLOBIN: 10.5 g/dL | MCH: 26 pg | MCHC: 30 gm % | MCV: 84 fl | PCV: 35 % | PLATELETS: 194 thou cells/ ul | RBC COUNT: 4.12 million/ul | TOTAL COUNT WBC: 7.16 Cells/cmm | FASTING PLASMA GLUCOSE (FPG): 595 mg/dL | GLYCOSYLATED HEMOGLOBIN (HBA1C): 10.6 % | HDL HIGH DENSITY LIPOPROTEIN: 43 mg/dL | LDL LOW DENSITY LIPOPROTEIN: 45 mg/dL | TGL TRIGLYCERIDE: 162 mg/dL | TOTAL CHO/HDL RATIO: 2.7 | TOTAL CHOLESTEROL: 115 mg/dl | POTASSIUM: 5.2 meQ/L | SODIUM: 139 meq/L | CREATININE: 1.22 mg/dL | FIB4: 1.34 | FIB4: 1.34 | FIB4: 1.34 | FIB4: 1.34 | EGFR EGLOMERULAR FILTRATION RATE: 48.28 mL/min/1.73m2 | EGFR EGLOMERULAR FILTRATION RATE: 48.28 mL/min/1.73m2 | DEXA MACHINE: GE - | HIP BMD: 0.734 g/cm2 | HIP T SCORE: -2.2 | SPINE BMD: 1.154 g/cm | SPINE T SCORE: -1.0 | |
|
S# |
Generic (Trade) Name |
Route |
Dosage |
Usage |
Duration |
|
1 |
CAPSULE CHOLECALCIFEROL 2000 IU
D RISE
Medicine For VITAMIN D |
PO |
0-0-1 |
AT BEDTIME
|
TILL NEXT VISIT |
|
|
2 |
INJ TRESIBA
DEGLUDEC |
|
0-0-12 UNITS |
AFTER FOOD
|
TILL NEXT VISIT |
| MAY CAUSE HYPOGLYCEMIA | |
|
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 SEMAGLUTIDE 0.5 MG
SUNDAE 0.5 MG
Medicine For DIABETES HEART KIDNEY PROTECTION |
SQ |
ONCE A WEEK |
AS DIRECTED NO RELATION TO FOOD
|
|
| MAY CAUSE GI OR VISUAL DISTURBANCES | |
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| Refill :
0 / Substitution: |
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| Education |
: |
| Next Visit |
: 07/Aug/2026 |
| Tests Suggested For Next Visit |
: FBS 2HPP |
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