CHANDER RAM

60 Y old Male, DOB: 15/12/1960

Account Number: 242746
WZ-78 4TH FLOOR TODA PUR DELHI, Landmark- Next To
Union Bank ATM, Central Delhi, DL - 110012
Home: 9560933773
Guarantor: CHANDER RAM Insurance: HCLT Dependent
Appointment Facility: HCL Healthcare Noida SEZ Center

21/04/2021 Dr Himanshu PandeMBBS, PGDCC,(General Physician),Regn.No.UPMC/49249

Reason for Appointment

1. VC Consult for EHC
2. On and Off Fever, Sore throat and cough since 2-3 days
3. Recent history of travel from Delhi to his home town.

Assessments/ Health Conditions Identified

1. Encounter for general adult medical examination - Z00.0 (Primary)
2. Type 2 diabetes mellitus - E11
3. Essential (primary) hypertension - I10
4. Hyperlipidemia unspecified - E78.5
5. Vitamin D deficiency - E55
6. Hyperuricemia without signs of inflammatory arthritis and tophaceous disease - E79.0
7. Benign prostatic hyperplasia with lower urinary tract symptoms - N40.1
8. Suspected COVID-19 - U07.2

Treatment  
1. Type 2 diabetes mellitus
Notes: Continue same treatment
Self-monitoring of Blood sugar by Glucometer (SMBG) and make a log
Review with SMBG after 4 weeks
Symptoms of Hypoglycaemia and its management explained.
Clinical Notes: Repeat Sugar profile after 3 months
B/L Retina screening (Fundus examination) yearly.

2. Essential (primary) hypertension

Notes: Continue same treatment
Home monitoring of Blood pressure.
Low salt, low fat diet as advised.
Target BP<120/80mmHg.

3. Hyperlipidemia unspecified
Notes: Continue same treatment
Lifestyle modification (Low fat, High fibre diet, weight management and physical activity as advised)
Repeat Lipid profile after 3 months.

4. Vitamin D deficiency
Notes: Cap UPRISE D 60000IU once weekly for 4 weeks then twice in a month for 3 months
Repeat Vitamin D after 3 months and review.

5. Hyperuricemia without signs of inflammatory arthritis and tophaceous disease

Start FEBUTAZ FILM-COATED TAB 40mg, once daily, 30 days
Notes: Avoid foods containing high purine such as red meat, oily fish, seafood, sugary drinks such as soft drinks. Maintain a
healthy weight. Regular exercise. Drink plenty of water.
Repeat Uric acid after 3 months and review.

6. Benign prostatic hyperplasia with lower urinary tract symptoms

Start URIMAX-D TAB, 0.4mg once daily at night, 60 days

7. Suspected COVID-19
Notes: Tab AZEE 500mg once daily for 5 days
Cap DOXY100mg twice daily for 5 days
Tab IVERMAC 12mg once dily for 3 days
Tab LIMCEE 500mg once daily for 15days
Tab DOLO 650mg 1 tablet as and when needed for fever >100*F
Tab ZINCOVIT once daily for 15 days.
Clinical Notes: Follow COVID precautions asadvised.

8. Others
Referral To:Urology
Reason:BPH

Referral To:Surgery
Reason:Ulcer on Leg

Labs  
Lab: CARDIOVASCULAR CARE PLAN(P586)
Lab: RTPCR(COVID-19)

Wellness Plan
Clinical Data:
Preventive Education
Given Yes
Care Plan Management:
Goals
Target Systolic BP (Less than ...) 120
Target Diastolic BP (Less than ...) 80
Target HbA1c (Short Term) (Less than ...) 6.5
Target HbA1c (Long Term) (Less than ...) 5.7
Target LDL-Cholesterol (Less than ...) 100
Target Exercise (Duration in min/week atleast) 150
Health Index score is 4.1
Based on the Clinical Assessment, Cardiovascular Care Plan is recommended
ADV: Eat healthy. Take green vegetables/ salads/ fresh fruits. Drink more water and other healthy drinks like buttermilk/ milk/
tender coconut water. Avoid oil/ spicy food. Consume tea and coffee in moderation.
Refrain from smoking and consuming alcohol.
Do light to moderate exercises daily. Keep a positive attitude.
Maintain good personal hygiene. Wash hands frequently.
Refrain from going outside in the present scenario unless for emergency and for buying necessities.
Stay well informed and follow the rules and guidelines.
DISCLAIMER: IF YOU FEEL ANY KIND OF ALLERGY AFTER TAKING THE PRESCRIBED MEDICINE IN THIS
VIDEO/AUDIO CONSULT, PLEASE DISCONTINUE THE MEDICINE AND GO TO THE NEAREST MEDICAL FACILITY/
DOCTOR FOR FURTHER EVALUATION AND MANAGEMENT.

Next Suggested Appointment

4 Weeks (Reason: FU)

History of Present Illness

Phase 3 Health Index:
Phase 3 Health Index Questionnaire
Do you have or had Diabetes – means high blood sugar problem or took or taking its treatment? Yes
Do you have or had Hypertension – means high blood pressure or BP or took or taking its treatment? Yes
Do you have or had any heart disease brain stroke or any other problem of heart, brain or blood vessels (means arteries or
veins related problem), or took or taking its treatment? No
Do you have or had any Thyroid related problems – means the thyroid glands of neck or took or taking its treatment? No
Do you have or had Asthma? No
Do you have or had Hyperlipidemia any problem of high blood cholesterol ? Yes
Do you have or had any Cancer or took or taking its treatment? No
CONSENT: Before initiation of the present consult, the patient/ consult beneficiary has been informed and explained about
the telemedicine (that is, the facility of virtual consult/tele-consult through a tele-health mode) and consent taken for the same.

Drug History
Taking
GLUCONORM-G FORTE FILM-COATED TAB 2mg/1g HALF TABLET BEFORE BREAKFAST AND BEFORE DINNER
ROZAVEL-F FILM-COATED TAB 10mg/160mg once daily at night
TELSAR-H TAB 40mg/12.5mg ONCE A DAY
Not-Taking/PRN
TAYO-60K TAB 60000IU ONCE A WEEK FOR 10 WEEKS AND THEN ONCE A MONTH FOR 4 MONTHS
DIAVIT PLUS SOFT-GELATIN CAP once daily AFTER LUNCH
 URIMAX MODIFIED-RELEASE CAP 0.4mg once daily at night
ZINCOVIT TAB ONCE A DAY
Other Medications HALF TABLET DAILY AFTER DINNER , Notes: TGLIP-M-(20/500)
MATILDA FORTE CAP once daily after food
Medication List reviewed and reconciled with the patient

Allergies
N.K.D.A.

Past Medical History

DIABETES-8 YRS.
HYPERTENSION-8 YRS.
HYPERLIPIDEMIA.
Acidity.

Surgical History
gall bladder stone

Hospitalization/Major Diagnostic Procedure

for the same

Family History
Mother: deceased
Father: deceased
Non-Contributory

Social History
Social History:
Physical Activity
Do you participate in at least 150 minutes of moderate-intensity aerobic activity at least 75 minutes of vigorous-intensity
aerobic activity, or an equivalent combination weekly? No
Sleep
Do you sleep for at least 6 hours daily on an average? Yes
Smoking -
Do you smoke? No
Tobacco -
Do you chew tobacco? No
Alcohol -
Do you consume alcohol? No
Stress
Over the last 2 weeks have you been bothered by the feeling of nervousness, anxiety, being on edge, or not being able to stop
or control worrying? No

Vital Signs
BP-NA ,HR-NA ,SPO2-NA,WT-NA,HT-NA
Q Risk2 score can't be commented in view of inadequate data.

Past Orders
Lab:HSC EXECUTIVE HEALTH CHECK - ABOVE 40 YRS MALE(P552H) (Order Date - 01/04/2021) (Collection Date -
02/04/2021)
ALANINE TRANSAMINASE (SGPT) 41.4 < 45 - U/l
ALBUMIN - SERUM 4.6 3.2-4.8 - gm/dl
ALKALINE PHOSPHATASE 93.7 45 - 129 - U/L
APPEARANCE CLEAR Clear -
ASPARTATE AMINOTRANSFERASE (SGOT
29 < 35 - U/l
)
AVERAGE BLOOD GLUCOSE (ABG) 174 H 90-120 - mg/dl
BACTERIA PRESENT Absent -
BASOPHILS 0.2 <2 - %
BASOPHILS - ABSOLUTE COUNT 0.02 0-0.1 - X 10? / ?L
BILE PIGMENT NEGATIVE Negative -
BILE SALT NEGATIVE Negative -
BILIRUBIN (INDIRECT) 0.33 0-0.9 - mg/dl
 BILIRUBIN - TOTAL 0.48 0.3-1.2 - mg/dl
BILIRUBIN -DIRECT 0.15 < 0.3 - mg/dl
BLOOD GROUPING O -
BLOOD UREA NITROGEN (BUN) 17.29 7 - 25 - mg/dl
BUN / SR.CREATININE RATIO 23.05 9:1-23:1 - Ratio
CALCIUM 9.89 8.8-10.6 - mg/dl
CASTS ABSENT Absent -
PALE
COLOUR Pale Yellow -
YELLOW
CREATININE - SERUM 0.75 0.6-1.1 - mg/dl
CRYSTALS ABSENT Absent -
EOSINOPHILS 2.5 0.0-6.0 - %
EOSINOPHILS - ABSOLUTE COUNT 0.2 0-0.5 - X 10? / ?L
EPITHELIAL CELLS 1-2 2-3 -
EST. GLOMERULAR FILTRATION RATE
100 >= 90 - mL/min/1.73 m2
(eGFR)
FASTING BLOOD SUGAR 133.9 H 70-99 - mg/dL
FREE THYROXINE (FT4) 1.13 0.7-1.8 - ng/dl
FREE TRIIODOTHYRONINE (FT3) 3.1 1.7-4.2 - pg/ml
HbA1c 7.7 H < 5.6 - %
HDL CHOLESTEROL - DIRECT 46 35-80 - mg/dl
HEMATOCRIT(PCV) 48.1 40-50 - %
HEMOGLOBIN 13 13-17 - g/dL
IMMATURE GRANULOCYTE
0.3 0-0.5 - %
PERCENTAGE(IG%)
IMMATURE GRANULOCYTES(IG) 0.02 0-0.3 - X 10? / ?L
LDL / HDL RATIO 3.7 H 1.5-3.5 - Ratio
LDL CHOLESTEROL - DIRECT 168 H 85-130 - mg/dl
LYMPHOCYTE PERCENTAGE 20 20-40 - %
LYMPHOCYTES - ABSOLUTE COUNT 1.61 1.0-3.0 - X 10? / ?L
MEAN CORP.HEMO.CONC(MCHC) 27 L 31.5-34.5 - g/dL
MEAN CORPUSCULAR
27.8 27-32 - pq
HEMOGLOBIN(MCH)
MEAN CORPUSCULAR VOLUME(MCV) 102.8 H 83-101 - fL
CANCELLED
DUE TO
MEAN PLATELET VOLUME(MPV) -
TECHNICAL
LIMITATION
MONOCYTES 2.5 0-10 - %
MONOCYTES - ABSOLUTE COUNT 0.2 0.2-1 - X 10? / ?L
NEUTROPHILS 74.5 40-80 - %
NEUTROPHILS - ABSOLUTE COUNT 6 2.0-7.0 - X 10? / ?L
NITRITE NEGATIVE Negative -
NUCLEATED RED BLOOD CELLS 0.01 <0.01 - X 10? / ?L
NUCLEATED RED BLOOD CELLS % 0.01 <0.01 - %
PH 5.5 5-8-
PLATELET COUNT 130 L 150-400 - X 10? / ?L
CANCELLED
DUE TO
PLATELET DISTRIBUTION WIDTH(PDW) -
TECHNICAL
LIMITATION
PLATELET TO LARGE CELL RATIO(PLCR) CANCELLED -
 DUE TO
TECHNICAL
LIMITATION
CANCELLED
DUE TO
PLATELETCRIT(PCT) -
TECHNICAL
LIMITATION
PROSTATE SPECIFIC ANTIGEN (PSA) 0.94 < 4 - ng/ml
PROTEIN - TOTAL 7.1 5.7-8.2 - gm/dl
RED CELL DISTRIBUTION WIDTH
16.7 H 11.6-14 - %
(RDW-CV)
RED CELL DISTRIBUTION WIDTH -
63.3 H 39-46 - fL
SD(RDW-SD)
RH TYPING POSITIVE -
SERUM ALB/GLOBULIN RATIO 1.84 0.9 - 2 - Ratio
SERUM GLOBULIN 2.5 2.5-3.4 - gm/dL
SPECIFIC GRAVITY 1.01 1.003-1.030 -
TC/ HDL CHOLESTEROL RATIO 5.3 H 3 - 5 - Ratio
THYROID STIMULATING HORMONE
1.92 0.3-5.5 - ?IU/ml
(TSH)
TOTAL CHOLESTEROL 242 H 125-200 - mg/dl
TOTAL LEUCOCYTES COUNT 8.06 4.0-10.0 - X 10? / ?L
TOTAL RBC 4.68 4.5-5.5 - X 10
TRIGLYCERIDES 213 H 25-200 - mg/dl
URIC ACID 8.1 H 4.2 - 7.3 - mg/dl
URINARY BILIRUBIN NEGATIVE Negative - mg/dl
URINARY GLUCOSE NEGATIVE Negative - mg/dl
URINARY LEUCOCYTES NEGATIVE Negative - Cells/ul*
URINARY PROTEIN NEGATIVE Negative - mg/dl
URINE BLOOD NEGATIVE Negative - Cells/ul*
URINE KETONE NEGATIVE Negative - mg/dl
UROBILINOGEN 0.2 <=0.2 - mg/dl
VITAMIN D TOTAL 18.05 L 30-100 - ng/mL
VITAMIN D2 0.44 . - ng/mL
VITAMIN D3 17.61 - ng/mL
VLDL CHOLESTEROL 42.6 H 5 - 40 - mg/dl
Notes: Support, Avitas 04/04/2021 08 Support, Avitas 04/04/2021 08:10:16>: This result has been marked as reviewed by
the Interface

Examination
General Examination:
Vitals & Reports noted. Happiness Index, latest ECG, ECHO/ TMT, CXR & Retina scan not done.
DISCLAIMER: This virtual consult/tele-consult has been done through telemedicine/tele-health mode as per the statutory
guidelines and for the same, utmost care was taken to address the concerns and the clinical requirements of the beneficiary/
patient as best as possible, but within limitations of this method of virtual consult , where physical examination was not possible
through this mode.
HELPLINE MESSAGE (HCL)- In case of any COVID related health urgency or emergency, please seek medical assistance
promptly. You can reach out to the 24x7 HCL Global Helpline (phone: 9211022223, email: Covid19@hcl.com) or seek help from
any nearby doctor/hospital.
Electronically signed by Dr Himanshu Pande on 21/04/2021 at 11:54 AM IST
Sign off status: Completed

HCL Healthcare Noida SEZ Center

3A Sector 126 Noida
Noida SEZ UP 201301
Tel: 0120-4543570
Fax:

HCL Avitas Pvt. Ltd.

Registered Office Address: 806 Siddharth 96, Nehru Place, New Delhi - 110019, India
CIN: U85100DL2011PTC264453
Website: www.HCLHealthcare.in

Patient: CHANDER RAM DOB: 15/12/1960 Progress Note: Dr Himanshu PandeMBBS, PGDCC,(General
Physician),Regn.No.UPMC/49249 21/04/2021
Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)