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Electronic Health Record

Raja Banerjee

45/A, K. L Goswami street

Serampore

PIN- 7112201

Phone- 8420753274

rb@healthcarebangla.com

Self Reported Demographics

Date of Birth: 1973-05-10
Age: 39
Gender: M
Occupation: Business
Organ Donor: Y
Height: 185.9
Chest: 109
Waist: 96.52
Blood Group: A+

Insurance

Insurance Status: Running
Insurance ID: ICICI 45888585
Insurance Company: ICICI Prudential
Insurance Amount: 100000

Emergency Contact Person

Name: Sourabh Ghosh
Address: 67/2, Panduah Road,Panduah Hooghly
Contact No: 9333981314

Allergies

Allergies Name Triggered By Allergies Status

Nickel Allergy

nickel or items containing the metal.

Active

Allergic Conjunctivitis (Pink Eye)

bacteria

Active

Pet Allergies

Cat

Inactive

Milk Allergy

Milk

Active

Immunization Details

Immunization Name Due Date Given Date

Diphtheria, Tetanus & Pertussis

1973-06-13

1973-06-13

HepA

2016-08-13

2015-04-13

Eye Test

Right Eye Vision: 6/9
Left Eye Vision: 6/8
Right Eye Power: -4.50
Left Eye Power: -2.0
Observations: Glass for constant use


Physical Exam Vitals

Blood Pressure History
BP Date
120/90 24-06-16
138/85 17-02-15
122/78 10-02-15
120/80 05-05-16


Height History
Height Date
172 21-08-10
178 27-03-12
180 20-06-15
182 19-05-16




Thyroid Test
T3 T4 TSH Date
1.05 9.3 2 14-11-03
1 8 2 16-05-19
1.01 9.40 1.86 13-06-18


Lipid Test
LDL VDL HDL Total Cholesterol Date
124 28 39 191 28-10-13
45 16 35 96 31-01-14


Kidney Function Test
UREA CREOTININ DATE
18 0.8 15-11-13
17 0.7 07-03-13
28 0.72 19-08-09
23 0.72 29-11-10


Liver Function Test
SGPT SGOT DATE
127 45 28-10-13
70 34 15-11-13
49 24 02-02-14


Pulse Rate
Pulse Rate Date
90 14-01-15
80 19-01-16
70 02-05-16
75 19-05-16


Temperature
Temperature °C Date
36.7777777778 09-05-16
38.8888888889 17-05-16
36.6666666667 19-05-16


Weight History
Weight in KG Date
90 18-11-15
82 14-04-16
87 19-05-16


Hemoglobin
Hemoglobin Date
11.9 18-06-12
18.2 11-07-15
13.7 13-06-16


Blood Sugar
Fasting PP DATE
85 120 02-05-16
140 216 28-10-13
113 130 31-01-14
111 108 19-08-09


HBA1C Score
Score Date
5.2 17-09-14
5 19-05-16
6.7 31-01-14


ESR
ESR Date
17 19-02-10
21 01-09-14
24 24-06-14
18 13-02-16


URIC ACID
URIC ACID Date
7 13-03-14
6.9 13-02-15
5.2 13-06-16


BILLIRUBIN
BILLIRUBIN Date
1.1 02-04-12
0.7 13-06-15
0.5 21-05-16


Sodium Potassium
Sodium Potassium DATE
134 3.2 21-05-12
142 3.7 03-05-15
140 4 10-06-16

Treatment History



Health Care Person: Kanchan Bondhopadyay

Reason for Visit: Anxiety
Diagnosis: Anxiety State
Vital: BP- 120/80, Pulse Rate- 100
Date: 2013-07-13


Paper Prescriptions


Lab Test Recommendations
USG, Chest Xray, Blood Sugar


Health Care Person: Kanchan Bondhopadyay

Reason for Visit: Blood Sugar Problem
Diagnosis: Blood Sugar Problem
Vital: Pulse rate: 78
Date: 2012-01-30


Paper Prescriptions


Lab Test Recommendations
Chest Xray, HBA1C


Health Care Person: Kanchan Bondhopadyay

Reason for Visit: Sleeping Problem
Diagnosis: Sleeping Problem
Vital: Pulse rate: 79
Date: 2013-05-15


Paper Prescriptions


Lab Test Recommendations
Blood Sugar


Lab Results

Glucose PP
Test: Lakhotia
Lab ID: 345
Lab address: 493/C/A G.T Road, Vivek Bihar, Block-E, Howrah
Test Results:
Comment:

Biochemistry
Test: Drug House Diagnostic Center
Lab ID: 9394
Lab address: 48A, B P Dey Street, Serampore
Test Results:
Comment:

Biochemistry
Test: Drug House Diagnostic Center
Lab ID: 9394
Lab address: 48A, B P Dey Street, Serampore
Test Results:
Comment:

Glucose PP
Test: Lakhotia
Lab ID: 345
Lab address: 493/C/A G.T Road, Vivek Bihar, Block-E, Howrah
Test Results:
Comment:

Hemoglobin
Test: Lakhotia Medical Center
Lab ID: 102-13
Lab address: 10, Dr. Abani Dutta Road, Golabari, Howrah-711106
Test Results:
Comment:

X-ray of Left Elbow
Test: Lakhotia Diagnosite Services Pvt. Ltd.
Lab ID: 013-038730/14-15
Lab address: 439/C/A, G.T. Road, Vivek Vihar, Block-E, Howrah-711102
Test Results: Compound fracture seen
Comment: Compound fracture seen

USG of Whole Abdomen
Test: Lakhotia Diagnosite Services Pvt. Ltd.
Lab ID: 013-038730/14-15
Lab address: 439/C/A, G.T. Road, Vivek Vihar, Block-E, Howrah-711102
Test Results: Severe Fatty Liver
Comment: Severe Faty Liver



Medical Documents

Prescription

Prescription

Lab Report

Prescription

Prescription

Prescription

Radiology Report

Lab Report

Hospitalization History

Hospital Name ID: Serampore Walshaw Hospital
Diagnosis: appendix
Hospitalization Date: 2015-07-15
Release Date: 2015-07-20
Discharge Summery: Appendicitis is a medical emergency that requires prompt surgery to remove the appendix.
Billing Amount: 8952

Hospital Name ID: Apollo Hospital Kolkata
Diagnosis: Fatty Liver
Hospitalization Date: 2016-05-14
Release Date: 2016-05-14
Discharge Summery: Ursomax 300 twice daily, Rosumac 10 Daily after diner, Low fat diet
Billing Amount: 40000



Surgery performed

Surgery Name: appendix
Hospital Name ID: Walse7888
Operated on: 2015-07-16
Surgeon Name: Dr. Apurba Adak
Surgical Report: Appendicitis is a medical emergency that requires prompt surgery to remove the appendix.


Surgery Name: Laparoscopic Gallbladder Removal
Hospital Name ID: Appl44511
Operated on: 2016-02-15
Surgeon Name: Dr. Pradip Ghosh
Surgical Report: Although there are many advantages to laparoscopic gallbladder removal, the procedure may not be appropriate for some patients who have severe complicated gallbladder disease or previous upper abdominal surgery. A thorough medical evaluation by your personal physician, in consultation with a surgeon trained in laparoscopy, can determine if laparoscopic gallbladder removal is an appropriate procedure for you.


Current Medications

Medicine Name Time of Taking Dose Frequency
Optive Fusion 50ml 2 drop 4 Times a day
Glucovita 300mg 1 Tab Twice Daily

Care Provider

Care Provider Name Contact Number Address
Kanchan Bondhopadyay 26522607 67, A. P Ghosh Road

Current Diet

1. Low fat diabetic diet
2. 1600 calories
3. More green and leafy vegetables

Life Style Change

1. Walk for 30 minutes
2. No stress
3. Sleep for at least 8 hours