test_L.csv

IP_NO,chat
34,"[{'role': 'user', 'content': '\nIP Number: 34\n\nPatient Number: 173\n\nPatient Name: T.M.ALEXANDER\n\nGender: M\n\nDate of Birth: 17-07-1935\n\nAddress: THUNDIPARAMBIL HOUSE\n\nPincode: nan\n\nPhNo: 9895405553\n\nAdmission Date: 23-08-2011\n\nDischarge Date: 06-09-2011\n\nDiagnosis determined by the doctor when the patient was admitted: Essential (primary) hypertension\nTYPE 2 DIABETES MELLITUS\nDIABETIC NEUROPATHY\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: nan\n\nXray information: nan\n\nClinical examination: nan\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: Constipation , vital stable, adviced Enema, continue the orders\nVitals stable , seen By Dr bhatt, X-ray of LT foot- chronic osteomyelitis\r\nGRBS- 187\n3:00am , passed motion , had itching , adviced Inj.Avil slow I.V, stat,stop Tab.chymoral forte\r\nSlept after the Avil injection. Vitals stable. seen by DR BHatt, X-Ray Foot taken- ? osteomyelitis,\r\nWill control the infection and sugar,  discussed the plan with the Pt\nSeenb by DR.A.K.Bhat\r\nAfebrile.\r\n?Plan for bone nibbling under LA.\nSeen by DR.A.K.Bhat\r\nDressings reviewed.\r\nThe options given are:\r\n1)conservative.\r\n2)Bone nibbling\r\n3)Debridement&fillet flaps of 2nd&3rd toes.\r\n8:00pm Better,vital stable, sugar under control\nvitals stable. still c/o itching a liitle bit\r\nAC- 114\nBetter, planned case in morning, follow the instruction , Shift the case to OT by 7:15pm\nVital stable, systemic Examination -Status co, Changed the antibiotics according to c/s, stop novomox Cv\r\nDisscussed with Dr.Bhat\nAcute retension of urine, vomiting\r\nAfebrile, PR 80/min , BP 150/90mmof hg, CVS-S1S2Normal , RS-Clear , \r\nCatherized , Inj.emeset 4mg i.v stat, Inj.Rantac I.V \r\n1:00pm  Inj.Perinorm stat, IV DNS 500ml + 6units Actrapid 50ml /hr, continue the advice asper the surgery notes\nBetter, No Nause, Vital stable , Insugen R 6units at  bed time, continue the same orders\r\nShift to ward tomrrow\nShift to room , vital stable, no vomiting , D/C Cath\r\nSeen by Dr.A.K.Bhat\r\nAfebrile.No soakage of dressing.No pain.\r\nContinue trea6tment.OFFLOADING of operated foot.\r\n\nVitals stable. c/o constipation.\nGC stable,Pruritis better.Taking oral foods.\r\nFBS- 153mg/dl\nVitals stable, Blood sugar control maintained.\r\nDressing change to be done by DR bhatt tomorrow\nVitals stable, prelunch- 71\nVitals steble. blood sugar controlled.\r\nDressing change today.\r\nSeen by Dr.A.K.Bhat\r\nDressing changed.\r\nDrain removed.Suture line is clean.\r\nContinue trt.\nSeen by Dr..AK Bhat\r\nPatient is not offloading the operated foot.Explained the need for offloading.\r\nContinue treatment.\nVitals stable Continue the same\nVitals stable . sugar well controlled, will discuss with Dr bhatt regarding the discharge process\nVitals stable, dressing change to be done tommorrow\nPt c/o different taste in the mouth. vitals stable. Blood sugar controlled\nSeen by DR.A.K.Bhat\r\nC&D done.Suture line of left foot is clean.\r\nSuggested oral antibiotics.\r\n\r\nVitals stable, blood sugar well controlled. Dressing change done. OFF loading of the feet\nDoing fine. General condition good. No hypos.\nSeen by DR.A.K.Bhat\r\nLarge dressing done.Partial suture removal done.The left foot wound is healing well.Adviced:OFFLOADING of operated leg.Dressing review twice a week.\nVitals stable, sugar well controlled.\r\nSutures to be removed today or tomorrow.'}, {'role': 'model', 'content': '\nIP Number: 34\n\nPatient Number: 173\n\nAdmission Date: 23-08-2011\n\nDischarge Date: 06-09-2011\n\nDiagnosis: chronic osteomyelitis\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\n\nClinical Exam(With BP): admitted for chronic ulcer on the plantar aspect of the Lt foot x 2 yrs,s/p amputation of the 5 th digit of the Lt foot  few months ago\r\n.\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: nan\n\nXray findings: Elderly male, not in any distress\r\nUlcer- Wagner 111 classification, on the planta aspect of the Lt foot in between the 2 and 3rd digit , probing to the bone.\n\nDiscussion: 76 yr old with H/o DM, admitted for non healing ulcer which was infected and probing to the bone. also swelling and pain in the Lt leg. X- Ray of the foot- destruction of the 2 and 3 rd metatarsal head of the LT foot. Seen by a surgeon, Started on I.V antibiotics and Insulin for good glycemic control.\r\nHe had an amputation of the 2 and 3 rd digit along with removal of the osteomyeltic  fragments on the metatarsal heads of the 2 and 3 rd digit.\r\ngrafting of the skin .\r\nRegular dressing were done.\r\n\n\nDiet: NUTRITION Dept:\r\nLow calorie, low fat, diabetic diet with small, frequent feeds adviced\r\nDiet booklet also given\r\n\r\n\n\nRemarks: nan'}]"
123,"[{'role': 'user', 'content': '\nIP Number: 123\n\nPatient Number: 2822\n\nPatient Name: SOPHY JOSEPH\n\nGender: F\n\nDate of Birth: 10-09-1951\n\nAddress: PAVANA HOUSE, KP VALLON ROAD\n\nPincode: 682020.0\n\nPhNo: nan\n\nAdmission Date: 27-10-2011\n\nDischarge Date: 12-11-2011\n\nDiagnosis determined by the doctor when the patient was admitted: TYPE 2 DIABETES MELLITUS\n\nData from scanning: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\froman\\fprq2\\fcharset0 Times New Roman;}{\\f1\\fnil\\fcharset0 Ms Sans Serif;}{\\f2\\fnil\\fcharset0 MS Sans Serif;}}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24                                                                             \\fs28  \\ul VENOUS DOPPLER\r\n\\par \\plain\\fs24 \r\n\\par \r\n\\par \\f1\\fs18                                             \\fs24   \r\n\\par \r\n\\par                                    Right Limb    :  Absant flow Rt Femoral and Poplital Vein\r\n\\par \\fs18 \r\n\\par \r\n\\par \r\n\\par \r\n\\par                                               \\fs24  Left Limb      :  Evidence of absant flow in Lt Femoral vein\r\n\\par                                                              Poplital vein shows  Normal flow                                       \r\n\\par                                                              \r\n\\par \r\n\\par \r\n\\par                                         \\f2 \r\n\\par }\r\n\n\nImpression data from scanning: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\fnil\\fcharset0 Ms Sans Serif;}{\\f1\\froman\\fcharset0 Times New Roman;}{\\f2\\fnil\\fcharset0 MS Sans Serif;}}\r\n{\\colortbl ;\\red0\\green0\\blue0;}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24           \r\n\\par THROMBOSIS/THROMBOPHLEBITIS OF Rt FEMORAL & POPLITAL  VEINS \r\n\\par THROMBOSIS OF Lt FEMORAL VEIN      \\cf1\\f1 \r\n\\par \\pard\\li1440                                                                                      \r\n\\par                                                                             \\fs28 Dr.Joe Antony \r\n\\par \\pard                                                                                 Consultant Radiologois \\cf0\\f2\\fs20 \r\n\\par }\r\n\n\nDiscussion: nan\n\nXray information: nan\n\nClinical examination: nan\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: Admitted for skin gafting\nVenous doppler -Tomrrow\r\nPR-80\r\nB.P 150/80\r\nCVS-S1S2 Normal \r\nRS-Clear\r\nCNS-Consious / Oriented \r\nPA-NAD\r\nContinue the same\nS/B Dr A.K.Bhat\r\nAdd Inj. Enoxaparin 60mg s/c B.D\r\nBlood Routine\r\nXray chest PA\r\nECG\r\nRFT\r\nLFT\r\nPlan for Skin grafting for tuesday morning\r\n\nVital stable, systemic examionation -NAD\r\nDoppler Venous \r\nContinue the same\nBlood transfusion \r\n1unit PCV\r\nInj.Lasix 20mg i.v stat\r\n\tinj.Avil 1amp i.v stat\r\ntransfusion on flow \r\nvital stable \r\nContinue the same\nital stable , fair glycemic control, \r\nLow Hb, Planned  Blood tranfusion \r\nAdviced \r\nSerum .Iron\r\nTIBC\r\nS.ferrtin \r\nContinue the same\r\nAdded Antibiotic\r\nS/b Dr.Sasikumar \r\nDVT\r\nStart on LMWH, stop on day of surgery\r\nStart on Oral anticogulation therpy after surgery , monitoir the PT/INR on therpy\r\nCan be taken for surger under moderate risk\n1units over at 2am , No rxn, \r\n2nd unit\r\nBlood tranfusion \r\n1unit\r\nPremedication\r\nInj.Avil 1amp i.v / Inj.Dexona sos\r\ncontinue the same\r\n\r\nVital stable \r\nConinue the same\r\nPBF/Iron profile awaited\r\nContinue the same\nHb/PCV\r\nTransfusion over , No rxn, vital stable\nSeen by Dr.AK.Bhat.\r\nFor SSG left foot&skin biopsy under SA on 1-11-2011.Get consent.C&D left foot.Shave genitalia&left thigh&betadine scrub HS&CM.Medical fitness for the procedure.IV antibiotics Inj.Microtaz 4.5 gm IV HS&CM.\r\n\r\nVITAL STABLE, NPO,FOLLOW THE DR.BHATT ORDRES\r\nHIGH RISK CONSENT\nVITAL STABLE,CONTINUE SAME\nPR-98/min\r\nB.p-124/67mmof Hg\r\nCVS-S1S2 Normal\r\nRS RR-24/min \r\nCNS-Consious /Oriented \r\nPA-Soft , NAD\r\nPain Better\r\nContinue the same\r\nInj.Fortwin 1amp / Phenargan 1/2 amp slow i.v sos\r\nTab.Nitreset sos\nVomitted once , C/o breathlessness\r\nSpo2 94%, PR-90/min, B.P120/80mof Hg\r\nCVS-S1S2 normal\r\nRS-NVBS\r\nCNS-Consious /Oriented\r\nInj.Pantodac 40mg IV\r\nInj.Emeset I.v \r\nCombimist Neb+derinide Neb stat\nGC better.Pt can be shifted from ICU.BP normal.\nSeen by Dr.A.K.Bhat.\r\nSome pain left thigh.Continue trt.\r\nC/o pain in th thigh and headache\r\npulse 0x at 12  am\nVitals stable. No pain at present\r\nPLan- Hold on the warfarin for now and start later.\nSeen by Dr.A.K.Bhat.\r\nFor change of dressing in OT tomorrow.\nVital stable, Continue the same\r\nContinue the same\nBetter\r\ndoing well\r\nRegular with Medication\r\nContinue the same.\r\nSeen by Dr.A.K.Bhat.\r\nDressing changed.SSG left foot has taken up.The donor site left thigh is clean.\r\nSuggested oral antibiotic.\nC/o Breathlessness\r\nC/o Abdomen discomfort\r\nFBS-111\r\nINR-1\r\nVital stable\r\nRS-Clear\r\nCVS-S1S2 Noraml\r\nMild odema over the Foot\r\nStoped tab.Deriphylline\r\nAxipan\r\nAdded tab.ravera D 1-0-1\r\nSyp.Sucrafil 10 ml 1-1-1\r\nContinue the same\nVital stable\r\nno specific complaint\nSeen by DR.A.K.Bhat.\r\nAfebrile.Continue trt.For change of dressing on wednesday.\nvital stable\r\nPT/INR-1.1\r\nContinue the same\r\nIncresed the warf 5mg 1-1-1\r\ncontinue the asame advice\nDoing fine. Not to ambulate as yet. No anitibiotics on board.\r\nPT/ INR tomorrow.\nfine\r\nHB, PCV, PT/INR\nSeen by Dr.AK.Bhat.\r\nDressings changed.The SSG left foot is settling well.The donor area left thigh healing well.\r\nVitals stable. will discharge only on saturday\nSeen by Dr.A.K.Bhat.Status better.No pain.Plan for discharge on saturday.\r\nTab.Deslar 5mg for cold st\nGC better.Slept well.Stool passed.Vitals stable.Continue the same.\r\nSeen by Dr.A.K.Bhat.Continue trt.\nfine\r\ncontinue the same\nSeen by Dr.A.K.Bhat.Dressings changed.Donor site fully healed.SSG taken up.\r\nAdvice on discharge:Dressing change left foot twice a week-Cuticell/pad/crepe bandage.Vaseline to left thigh thrice a day.Partial weight bearing left leg.Review after 2 weeks.'}, {'role': 'model', 'content': '\nIP Number: 123\n\nPatient Number: 2822\n\nAdmission Date: 27-10-2011\n\nDischarge Date: 12-11-2011\n\nDiagnosis: Essential (primary) hypertension (I10)\r\nTYPE 2 DIABETES MELLITUS (SL13)\r\nDIABETIC FOOT-Necrotising Fascitis\r\n ?FILARIASIS-RT\r\nGlaucoma\r\nImpetigenous Lesion all over both lower limbs\r\nUrosepsis \r\n\r\n\n\nClinical Exam(With BP): Admitted for grafting of the ulcer on the dorsum of the LT foot\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: nan\n\nXray findings: Elderly female, obese, not in any resp distress\r\nRS- NVBS\r\nCVS- S1 S2 heard\r\nAbdomen- Normal\n\nDiscussion: Pt admitted for skin grafting of the ulcer on the dorsum of the Lt foot. Venous doppler was done- Thrombosis of both the femoral and popliteal vein. Pt was started on Low molecular Wt heparin. Pt was noted to have low HB, investigation were done and was transfused 2 units of PRBC , SSG was performed on 1/11/2011,  with the graft taken from the Lt thigh. skin biopsy was taken from one of the impetiginous lesion.\r\nPt was started on I.V antibiotics, insulin basal bolus regimen, started on Tab Warfarin, while continuing on the inj low molecular wt heparin. INR therapeutic, and heparin stopped.\r\n\r\n\n\nDiet: nan\n\nRemarks: nan'}]"
346,"[{'role': 'user', 'content': '\nIP Number: 346\n\nPatient Number: 5426\n\nPatient Name: SEETHA MANI\n\nGender: F\n\nDate of Birth: 03-03-1958\n\nAddress: MAVUNGAL THARA, PALLURUTHY\n\nPincode: 682005.0\n\nPhNo: nan\n\nAdmission Date: 18-03-2012\n\nDischarge Date: 03-04-2012\n\nDiagnosis determined by the doctor when the patient was admitted: DIABETIC NEPHROPATHY WITH MICROALBUMINUREA\nTYPE 2 DIABETES MELLITUS\nEssential (primary) hypertension\nDIABETIC  NEPHROPATHY\nMixed hyperlipidaemia\n\nData from scanning: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\froman\\fprq2\\fcharset0 Times New Roman;}{\\f1\\fnil\\fcharset0 MS Sans Serif;}}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24 \r\n\\par \r\n\\par \\tab\\tab                  \\ul\\b  ULTRASOUND SCAN REPORT\r\n\\par \\plain\\b0 \r\n\\par \r\n\\par \r\n\\par \\b Liver\\b0\\tab                         :  \\b  Mild Fatty changes\r\n\\par \r\n\\par Gall Bladder\\tab\\tab :   Well distended. No calculus or sludge.CBD is not dilated.\r\n\\par \\tab .\r\n\\par Pancreas\\tab\\tab :   Normal in size & echo texture. No calcification. No duct dilatation.\r\n\\par                                                           \r\n\\par Spleen\\tab\\tab\\tab :   Normal in size & echo texture. No evidence of any focal lesion.\r\n\\par \r\n\\par Kidneys\\tab\\tab :   Both kidneys show mild vessel parenchymal oedema.s/o nephritis\r\n\\par \r\n\\par Urinary Bladder\\tab :   Well distended. No calculus. No wall thickening.  No mucosalirregularity.\r\n\\par                                             \\tab                        \r\n\\par Prostate\\tab\\tab :   Normal in size & echo texture.\r\n\\par \\b0 \r\n\\par \r\n\\par \\b No free fluid in the abdomen.\r\n\\par \\b0 \r\n\\par \r\n\\par \\tab \r\n\\par \r\n\\par \\tab\\tab\\tab\\tab\\tab\\tab  \\tab\\tab \r\n\\par \\tab\\tab\\tab\\tab\\tab\\tab\\tab\\tab  \r\n\\par                                                                                           \r\n\\par \\f1\\fs20 \r\n\\par }\r\n\n\nImpression data from scanning: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\froman\\fprq2\\fcharset0 Times New Roman;}{\\f1\\fnil\\fcharset0 MS Sans Serif;}}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24 Mild Fatty changes.\r\n\\par Kidney show mild vessel parenchymal oedema s/o nephritis.\r\n\\par No evidence of Ascitis.\\f1\\fs20 \r\n\\par }\r\n\n\nDiscussion: nan\n\nXray information: nan\n\nClinical examination: nan\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: INV- URE, RFT, CBC, ECG\r\nADV- place a rubber catheter\r\n         INJ pantoprazole 1amp iv stat\r\n         continue all medications\r\n\r\nXray Chest PA- Blusting of CP angle\r\nstool for occult bloot\nPR-70/min\r\nB.P-150/70\r\nRS-Crepitation\r\nInj.Lasix 40mg I.V stat\r\nAdded Beta Blocker, Nitrate\r\n\r\n\r\n\nC/o nausea\r\npatient better\r\nvitals stable\r\nchest- clear\r\ncvs-s1s2 n\r\nADV-T. axipan 40mg\r\n\nChest is better,\r\nPuffiness of face has reduced a bit\r\nOut put is better\r\nHb\r\nPCV\r\nBlood group\r\nCreat\r\nUrea\r\nNa+\r\nK+ \r\nAlk PHos\r\nCalcium\r\nS.Albumin\r\nANA\r\nPlan: Blood tranfusion\nPR-70/min\r\nB.P-150/60mmof hg\r\nCVS-s1s2 Nor4mal\r\nRS-Few crepitation\r\nCNS-Consious/ oriented\r\nHad Hypoglycemia in morning\r\nwith hold the Metformin , \r\nGive Eurepa\r\nStop 5% Detrose\r\nInj.lasix 40mg I.V given\r\nLasilactone withhold\r\nstop Inj.lasix\nvitals stable , B.P- 150/70.\r\nI-800\r\nO- 800, Feels better. adjusted the dose of OHA\r\nGRBS- 249\n1800: Generally better, BP 150/80, pulse 78/min, afebrile, O2 sat 98%. I/O 850/900ml since AM.\r\nChest- better, no creps, facial puffiness less.\r\nPlan- Give Dytor 5mg in AM, Calcheck 5mg hs.\r\n\nS/B Dr.Sasikumar\r\nBounding pulse\r\nB.P-180/80\r\nRS-few crepitation\r\nReduced the dose of Betablocker\r\nAdd Tab.amlodipine\r\nreduced the diuretics\nHypoglycemia at 3am\r\nI.v Dextrose given \r\nFBS-175\r\nStop Metformin\r\nAdded ravera d\r\nreduced the B blocker\r\nContinue the rest\r\nNephroconsultation\nS/B Dr.Abdul rasheed\r\nLoss apptite\r\nNause\r\nVomiting\r\nUrine Retension \r\nCr-1.3\r\nHydrated\r\nVital stable\r\nIntake =output\r\nCatherise\r\nInj.lasix sos\r\nNa+,K+,CA+,Phos+, Uric acid,Creat Urea -Tomorrow\r\n\r\n9 45pm\r\nVomited once\r\nNS 50ml/hr\r\nInj.Emeset 4mg I.V\nLFT\r\nSGPT High\r\nLOw Protein\r\nPT derranged\r\nInj.Vit K 1amp I.M \r\nTab.Udliv 300mg 1-0-0\r\nLooz 15ml HS\r\nUSG ABD -MOndays\r\nCheck -Na+ Tommorow\nStop Diuretic \r\nLFT\r\nPT/INR\r\nHyponatrimia-Diuretic Induced \r\nContinue the same\nGC slightly better. Has not vomitted since yesterday. NA+ 117. \r\nNa+, Se Creat, K+ tomorrow, USG abdomen\nseen by RMO\r\nc/o tiredeness\r\npuffiness of face present\r\nADV: continue same treatment\nC/o fever, Temp- 100, Pulse Oximetry- 84 on RA, HR- 98/min\r\nNa after 6 bottle of 100ml is 115, creatinier increased to 1.6\r\nPt was not in resp distress\r\nSeeen By Duty doctor, given Inj lasix 60 mg I.V stat and shifted to the ICU as per instruction by DR lakshmi\r\nNot in acute distress\r\nRS-Basal creps, distended neck Veins\r\nON 4 L 02\r\nsaturation now- 97-98\r\nB.P- 169/70, started in I.V NTG at 5 mcg/min\r\nPulse- 82/min\r\nCheck Urine Re, Blood RE, CKMB, trop I, AST, ALT, Pt/INR, Urea\r\nTo give stat dose of piperaccilin/tazobacatam after ureine RE and Cx taken\r\nCheck Na+, Se Creat at 4 pm today\r\nBRE tomorrow\r\n\nseen by dr.lakshmi n dr.muneer\r\nB.P- 170/75 mmhg on I.V nitro 5 mcg/min, will slowly taper it off\r\nOn 02 2 l\r\nPulse- 82/min\r\nNot in any distress\r\nNa- 118, creatinine - 1.5\r\nUSG- Nephritis, Mild fatty liver changes\r\nNo fever, on Inj piperacillin/tazobactam\r\n\r\n10.30 pm\r\nbp-168/56 mmhg\r\npulse-80 bpm\r\nspo2-98 with 1L O2 on flow\r\npt sleeping\nC/o fever, Temp- 100, Pulse Oximetry- 84 on RA, HR- 98/min\r\nNa after 6 bottle of 100ml is 115, creatinier increased to 1.6\r\nPt was not in resp distress\r\nSeeen By Duty doctor, given Inj lasix 60 mg I.V stat and shifted to the ICU as per instruction by DR lakshmi\r\nNot in acute distress\r\nRS-Basal creps, distended neck Veins\r\nON 4 L 02\r\nsaturation now- 97-98\r\nB.P- 169/70, started in I.V NTG at 5 mcg/min\r\nPulse- 82/min\r\nCheck Urine Re, Blood RE, CKMB, trop I, AST, ALT, Pt/INR, Urea\r\nTo give stat dose of piperaccilin/tazobacatam after ureine RE and Cx taken\r\nCheck Na+, Se Creat at 4 pm today\r\nBRE tomorrow\nGC slightly better. Na+ 120, TC- 14,500\r\nIntake 500, Output 750 ml\r\nS/B Nephrologist, advised oral hydration\r\nRpt Na+, K+, BRE tomorrow\r\n\r\nS/B Dr Lakshmi\r\nStable\r\nHb,Na/K, Se.Cr,TC tomorrow\nGeneral condition slighlty better. Counts have come down to 11,000 cell/ mm3. Se Creat is down to 1.2 mg/dl. Hb has dropped to 7 mg/dl. Repeat Hb.\n0845: Generally better. V/S stable.\r\nElectrolytes improved- Na 126, K+ normalised. \r\nCreat 1.4-stable.\r\nHb improved 9gm%, TC normal today.\r\n\r\n1400: D/W Nephro- To give diuretics monitoring Na/K levels.\n1915: S/B Dr. Kenny-\r\nWas assessed by P/T & pt. stoodup with support.\r\nI/O-450/400ml till 5pm. GRBS 149mg%, BP 150/80, P-80/m\r\nHas some cough & orthopnea. O2 sat 90%@room air.\r\nChest- few medium creps till infrascapular area.\r\nPlan: Inj Lasix 20mg IV slow. Get Urine C/S report.\r\nCont. all above. Check Na/ K, Bicarb, BUN tomorrow AM.\ncontinue to have basal crepitations.BP - 150/80mmhg.General condition better.output-1200ml.Intake 1100ml.Pt slightly febrile.S.Creatinine,BRE.Sodium,potassium at 3.30pm\nvitals stable,BP 150/70mmHg\r\nbasal crepts +\r\nO2 onflow 6L, Na-125,K-3.4\nDoing well.Basal crepitations present.Counts have normalised.Saturation with 2l of oxygen 91%,Off O2- Saturation dropping.Have advised IV diuretics.FBS - 84mg%.\nvitals stable,BP 150/70mmHg\r\nbasal crepts +\r\nO2 onflow 6L, Na-125,K-3.4\r\n\r\n31/3/12- 9am: S/B Dr. Kenny-\r\nPt. comfortable thru the night. O2 sat maintained between 92-94% on 2L O2 by facemask. Has decreased appetite.\r\nO/E Chest- medium creps infrascapular areas b/l.\r\nNo fever. No pedal edema.\r\nPlan- Low dose IV lasix 20mg bd.BP : 160/80mmHg.\r\n\r\n31/3/12- 1845: S/B Dr. Kenny- Stable, ate lunch & had tea.\r\nPlan- cont.O2 @1L/hr maintainence.\r\n\n7.15 pm\r\nseen by dr.muneer\r\nbp-160/80 mmhg\r\ngrbs-192 mg/dl\r\nspo2-74\r\nno fever\r\nc/0 breathing difficulty at times\r\ncontinue same\nStill continuing to have basal crepitation. Increase Inj Lasix to 40 mg IV BD. CBC, RFT, Se Electrolytes tomorrow\nBreathlessness\r\nPR-70/min\r\nB.P-180/100\r\nSpo2-78% \r\nCVS-S1s2 Normal\r\nRS-Basal crepitation\r\nInj.Lasix 40mg + 40mg \r\nI.V NTG 5mcg\r\nXray Chest PA\r\nECG-St strain V4v5\r\nShift to ICU\r\nO2 10l/min \r\nCombimist +Derinide Neb 1-1-1\r\nECG\r\nCKMB\r\n\r\nINJ.DYNALIX 0.4 S/c\r\n6 00 pm \r\nPR-69/min\r\nB.P-130//60 mmof hg\r\nCVS-S1S2 Normal\r\nRS crepitation\r\nCNS-Consious Oriented\r\nO2 Onflow\r\n10L\r\n\r\n9pm\r\nPR-75/min\r\nB.P-145/56 mmof hg\r\nCVs-S1S2 Normal\r\nRS-Few crepitation\r\nECG T inversion in V456 Lead 2\r\nCKMB -52\r\nReduces the o2\nPR-84/min\r\nB.P-120/70mmof hg\r\nRS-Basal Crepitation\r\nCVS-S1S2 Normal\r\nI/O-1100/1700\r\nContinue the insulin\r\nLasix Tab\r\nSpo2 -Q2h\r\nIntake=Output\nBibasilar crepitations still persisting. Saturation dropping off O2. NTG on flow. BP-156/ 60 mm of hg. SP02- 93 % on 6 lits of O2. Vomitted once. AC- 209 mg/dl. ECG- STT changes V4-V6. CKMB elevated. LMWH given. Plan to shift to higher center for further mangement.'}, {'role': 'model', 'content': '\nIP Number: 346\n\nPatient Number: 5426\n\nAdmission Date: 18-03-2012\n\nDischarge Date: 03-04-2012\n\nDiagnosis: CCF  NYHA GRADE 1 (on admission) progressed to Grade IV in hospital\r\nAneamia secondary to CRF\r\nAccelerated HTN- uncontrolled with multiple drugs\r\nMild AR\r\n(re)pseudoaphakia+(le)cataract+mild NPDR\n\nClinical Exam(With BP): {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Verdana;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs17 Admitted with Uncontrolled blood pressure and puffiness and swelling in the face and mild pedal oedema and shortness of breath. She is a known diabetic under our care for 2-3 years. Had an amputation of Left 2nd and 3 rd toe elsewhere.\r\n\\par }\r\n\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Verdana;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs17 \r\n\\par \r\n\\par \r\n\\par }\r\n\n\nXray findings: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Verdana;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs17 Thin lady , not in any distress without any distress\r\n\\par RS- Basal creps +\r\n\\par }\r\n\n\nDiscussion: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Verdana;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs17 54 yr old with H/o DM, HTN admitted with puffiness of face and uncontrolled HTN, Initial CXR was sugegstive of  CC failure(CV angle blunting). she was diuresed. cardiac consultation was obtained, 2 D echo- Normal LV function, mild AR. She had problem with voiding and complained  of pain in the suprapubic region. Foley was placed. Diuretics was stopped because of hyponatremia, attempt to correct Na+ with Hypertonic saline was made. Na+ levels came up marginally (125 meq/L) she had  episode of  hypoxia, was  shifted to ICU, Diuretics was given, Creatinine increased from 1.2 to 1.7,along with urea. Urine RE - 40-45 pus cells. started on antibiotics. RUQ sonogram done- was suggestive of  Nephritis. Seen By Nephro. Adviced to keep Input slightly more than the output. Pt clinically improved. Reduced dose of diuretic in view of dropping Na+ levels.  Developed orthopnea yesterday (2-4-12) (after diuretic dose was reduced). Moved her into the ICU. Put on NTG and incresed dose of diuretics. ECG suggestive of ? ACS and CKMB elevated (52 IU). LWMH given. Na levels increased and creatinine came dowm to 1.4, counts also decreased. She continues to destaturate off 02 and persisting to be in CCF nad hence referred to a higher center for expert Mx.\r\n\\par }\r\n\n\nDiet: nan\n\nRemarks: nan'}]"
355,"[{'role': 'user', 'content': '\nIP Number: 355\n\nPatient Number: 4055\n\nPatient Name: KUNJAMMA MAMMAN\n\nGender: F\n\nDate of Birth: 12-12-1936\n\nAddress: VELLAPATT HOUSE, ASRAMAM WARD\n\nPincode: 682026.0\n\nPhNo: 0477 2233681\n\nAdmission Date: 25-03-2012\n\nDischarge Date: 14-04-2012\n\nDiagnosis determined by the doctor when the patient was admitted: TYPE 2 DIABETES MELLITUS\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: 75yr old with h/o Cholangio carcinoma stage 4 admitted with poor oral intake and change in mental status.\n\nXray information: nan\n\nClinical examination: Elderly female not in any respiratory distress responding to stimuli ,moving all extremities.\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: C/o Not taking anything oraly since yesterday. \r\nNot speaking anything since yesterday.\r\nNo fever.\r\nB.P- 130/80\r\nOximetry- 94 on RA \r\nCheck urine RE, Urine Cx\r\n B RE, SGPT, SGOT, T. Bi\r\nNa , k\nGC better with antibiotics. Blood sugar control is fair\nseen bydr.lakshmi n dr.muneer\r\nbp-130/80mmhg\r\ngrbs-118mg/dl\r\npt not taking oral feeds\r\nivf DNS 500 ml \r\ncontinue same\nSeen by RMO\r\nC/O abd. discomfort as said by bystanders\r\nO/E\r\nvitals- stable\r\ncvs -s1s2 n\r\nRS- B/L NVBS\r\nP/A- Soft, Non tender, BS+\r\nADV\r\nInj pansec 40mg IV BD\nnot taking anything orally, drank a little bit of juice.\r\nNot talking, \r\nNo fever.\r\nB/P- 120/70\r\nPule- 82/min.\r\nhas not passed bowel for 2 days.\r\nK- 3.1, will replace in the fluids\r\nSpoke to the urologist, will continue with the existing catheter and then after 2 days, will remove and before going will re- insert another catheter\nRTF -100 ML/hour. Overall GC better. Passed stools.\nvitals stable,drowsy\r\ncheck count,Se.Na/K tomorrow\n1845: S/B Dr. Kenny-\r\nNo fever, Had some shivering at 3.45pm, then resolved. GRBS 207mg%. \r\nDr. Majo contacted- says to manage conservatively as pt. stuporose & on R/T.\r\nUrine C/S- no sig. bacteruria.\r\nPlan- Change to IV Ciptec.\n9am: Stable, tolerating R/T feeds.\r\nHad 100*F this morning, tepid sponging done.\r\nRt.lower canine infected & relatives say painful, want extraction.\r\nPlan- Dental consult.\nRemove catherisation.Ryles tube feedings 1.5l in 24hrs.no fever.Rpt Sodium,potassium,Blood cpount,BRE tomorrow.General condition slightly better.FBS - 189mg%\nvitals stable,GRBS 213mg/dl\r\ndental check up done. maxillary canine teeth impinging on the lips.all the remaining teeth are periodontally week.\r\nmay require selective extraction of teeth Dr majo\r\n\r\n\nGc status quo. Occassional sweats. RBS during sweating episode was 230mg/dl. Total counts gone up.\nVomited RTF.\r\n status quo.\r\n\r\n1830: S/B Dr. Kenny.\r\nTolerated reduced am. of RT feeds. V/S stable.\r\nHad semifromed yellow stools twice.\r\nPlan: cont same.\n7.15 pm\r\nseen by dr.muneer\r\npt unconcious\r\nbp-150/90 mmhg\r\ngrbs-181 mg/dl\r\nno fever\r\ncontinue same\nConciousness level is slighlty better. BP- 140/90. Afebrile. CBC, Se eletrolytes. Repeat all\nFBS : 211mg%.BP : 130/70mmHg.GC fair.Rpt sodium.Provide water bed.Advise CVP line.\ncontinue the Sodium correction\r\nadviced\r\nPeripheral Venous cath tommorow\r\nTomorrow\r\nSodium\r\nPotassium\r\nUrea \r\nCreat\r\nRBS\r\nUrine for sodium\r\n\nS/B Dr.Mohan nair \r\nRyle tube feeding\r\ncorrect Hyponatrimia\r\nContinue the antibiotic\r\nVenous acces \r\n1) Peripheral Cath\r\n2) Central Vein\r\nPain less\r\n1)Oral morphine\r\n2) Patches\r\nDNR status\r\nPrognosis explained to the Bystanders\r\n\nVital stable\r\nNa+-130\r\nE1M4V2\r\nRS-Crepitation +\r\nstop 3% saline\r\nRyle tube insitu\r\ncath insitu\r\ncontinue the same\r\n\nCVP put in.GC fair.Rpt S.Electrolyte,CBC tomorrow.\nvitals stable,RTF 150ml given\r\nRS clear,GRBS-91mg/dl\nS/B DR. Kenny:Leucocytosis 25.2K, 86% neurophils\r\nNa+ dropped to 123meq/l\r\nConsious level same\r\nVital stable\r\nContinue the antibiotics\r\nNursing care\r\nPhysiotherapy\r\nUrine spot sodium\r\nBlue discolorartion over the toes, adviced scoks\r\nIncrease salt intake in RTF.\nS/B Dr. Kenny:\r\nNo new c/o, Lt. foot less bluish with socks but cold.\r\nUNa  37mmol/L. GRBS 163mg%.\r\nChest clear.\r\nPlan- Cont. all above.\nstatus Cop Na+, K+ Tomorrow\nstatus co\r\nvital stable\r\nchest clear\r\nContinue the rest\nBluish discolouration over toes.GC Satus Quo.Na level 118meq/l.  3% NS at 25ml /hr for 14hrs.FBS : 190mg%.Rpt CBC and S.electrolytes,RFT today at 4pm\nGC status quo, BP 130/80mmHg\r\nNa-111,K-3\r\n3% saline on flow 25ml/hr, Chest clear\r\nTC- 19,100 ,urea-70, creatinine-0.5,GRBS-118mg/dL\r\nIncrease 3% saline to 30ml/hr over 24hrs\r\nsyp.potklor 15ml bd\r\nrpt NA/K tomorrow\nStatus  quo\r\nNa-124\r\n3% saline onflow 20ml/hr\r\nGRBS-\r\n\r\nS/B Dr.Deepak L\r\nstatus Quo\r\nE1M3V1\r\nShallow respiration\r\nUrine Out put Decresed\r\n3% saline onflow\r\n\nstatus Quo\r\nGRBS-189mg/dL\r\nintake-600ml\r\noutput-500\nGC- Staus quo. Na+ 124 meq/l. Frequent change of posistion been given. SP02- 91 %, PR-115/ mt.\nGasping\r\nSpo2 45%\r\n0n O2 \r\nConected to monitoir\r\nVital stable\r\nDNR status\r\n\r\n\r\n200pm\r\nOn O2 L\r\nSpo2 99\r\nPr-100\r\nB.P 110/80\r\nRS-Deepo breathing\r\nCNS- Pupil Reactive\r\nLt hemi\r\nE1M4V1\ncondition same,explained to the bystanders\r\nspo2 99% with o2\r\nbp:130/80,HR:138\r\nDNR\n9am: status quo.\r\nUrine output only 500ml last 24 hrs, intake 890ml.\r\nBP 133/85, O2 sat 97-98% on 2L/min.\r\nE1 M4V1\r\nRS-Crepitation \r\nDNR status \r\nDisconnect the monitoir\r\nContinue 02\nS/B Dr. Kenny-\r\nV/S status quo. BP 130/90, O2 sat 98% on 2l/min.\r\nUrine output 200ml since AM.\r\nPain Rt. forefoot on movements.\r\nCont. all above.\nDark Red aspirate from ryles tube\r\n?Stress Ulcer\r\nInj.Pantodac 40mg 1-0-1  \r\nSyp .sucrofil  10ml 1-1-1\nPatient passed semi solid malaena\r\ngangrene Rt. Big toe, 2nd, 3rd and 4th toe\r\nBP- 130/90, Pulse-78/min, \r\nADV: Syp sucrofil 10ml tds\r\n         Inj. novomox cv 1.2gm IV BD\r\n         continue rest of the treatment\r\n\nContinue the same\nGasping \r\nE1M1V1\r\nVital stable \r\nContinue the same\n7-00am\r\nNo Pulse\r\nB.P Not recordable\r\nCVS-No S1,S2\r\nRS-No Breath sound \r\nCNS-Pupil dilated and Fixed \r\nECG -No Activity\r\nDeclared death at 7am on 14/4/2012\r\n'}, {'role': 'model', 'content': '\nIP Number: 355\n\nPatient Number: 4055\n\nAdmission Date: 25-03-2012\n\nDischarge Date: 14-04-2012\n\nDiagnosis: nan\n\nClinical Exam(With BP): {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Verdana;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs17 75yr old with h/o Cholangio carcinoma stage 4 admitted with poor oral intake and change in medical status.\r\n\\par }\r\n\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Verdana;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs17 \r\n\\par }\r\n\n\nXray findings: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Verdana;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs17 Elderly female not in any respiratory distress responding to stimuli ,moving all extremities.\r\n\\par }\r\n\n\nDiscussion: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Verdana;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs17 Pt was admitted with change in mental status and poor oral intake.Was noted to have UTI,started on antibiotics naso-gastric tube was placed for enteric feeding.Palliative care to be given.\r\n\\par }\r\n\n\nDiet: nan\n\nRemarks: nan'}]"
503,"[{'role': 'user', 'content': ""\nIP Number: 503\n\nPatient Number: 6271\n\nPatient Name: SUBAIR K A\n\nGender: M\n\nDate of Birth: 25-05-1962\n\nAddress: KANELIL HOUSE, EDAVOOR P.O\n\nPincode: 683544.0\n\nPhNo: 2640376\n\nAdmission Date: 27-06-2012\n\nDischarge Date: 11-07-2012\n\nDiagnosis determined by the doctor when the patient was admitted: Essential (primary) hypertension\nTYPE 2 DIABETES MELLITUS\nDIABETIC FOOT\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: 50yr old male admitted here for skin grafting. Rt. mid foot amputation and fasciotomy was done one month back.\n\nXray information: nan\n\nClinical examination: Temperature   :97.4\r\nRespiration     :22\r\nBP                 :140 / 70\r\nLocal Examination  :Clean raw areas\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: 1630: S/b Dr. Kenny-\r\nAdmitted from Podiatry for SSG.\r\n\r\n1830: no new c/o. GRBS 146mg%.\r\nTomorrow AM check Hb, Creat.\nSeen by DrA.k.Bhat.\r\nFor SSG under SA on 30th.Daily oxum dressing.Leg elevation.Blood TC,DC.ESR,Na,K..\ncame in for grafting. Hb- 10.1\r\nsugar conttrolled\r\nCreatinine- 1.0\r\nGrafting tomorrow\nFeels well.Skin grafting tomorrow.\r\nCounts slightly high.\nSeen by DR.A.K.Bhat.\r\nFor SSG under SA on 30th 4pm.Preop.:Nil oral as per anesthetist.Consent.Shave genitalia and rt thigh and betadine scrub.C&D rt foot in the morning.IV antibiotics from today.Inj.Cefaperazone+sulbactum 1.5 gm bd.\r\n\r\n\r\n\r\nS/B Dr. Raees\r\ncase posted for tomorrow's SSG\r\nno complaints\r\nsystems- NAD, Vitals- stable, pre dinner GRBS- 177mg%\r\nADV: follow anaesthetist orders\r\n        continue same\n10:30 AM: s/b Dr. Kenny-\r\nScheduled for SSG under SA at 4 PM.\r\nNPO after light lunch at 11 AM.\r\nMedically fit for Surgery.\n1800: S/B Dr. Kenny-\r\nSkin grafting done, postop stable.\r\nPlan: cont. same.\r\n\r\n\r\n22:00\r\nS/b Dr Biju.\r\ndoing well. BP - 145/85\r\nGRBS - 184mg%\r\nstarted oral feeds.\r\nInsugen N - 12U.\nS/B Dr. Raees\r\nno complaints\r\nsystems- NAD, Vitals- stable\r\npre dinner GRBS- 267mg%\r\ncontinue same\nSeen by DR.A.K.Bhat.\r\nPain rt thigh.No soakage.\r\nContinue treatment.Frequent change of position.\r\n\r\n\r\nGC - good. V/S stable. Pt may be shifted out.\nSeen by DR.A.K.Bhat.\r\nPain rt thigh.No soakage.\r\nContinue treatment.\r\n\nS/B Dr Babu-- patient c/o itching at skingraft site On cetrizine to continue same otherwise stable.\nSeen by DR.A.K.Bhat.\r\nContinue treatment.For change of dressing tomorrow.\r\n\r\nPain at the graft site with some itching. \r\nno other complaints...sugar well controlled.\r\ncontinue same.\r\n\n1800: S/B Dr. Kenny-\r\nItching less, has constipation & T.cruris.\r\nAdv- Syp. Loos 15ml stat. Candid cream L/A bd.\nSeen by DR.A.K.Bhat,\r\nDressings rt leg changed.SSG taken up.Continue trt.\r\n\r\n10:00 am-\r\nS/b Dr Kenny\r\nc/o itching at SSG site. Pre dinner GRBS - 186mg%\r\nPlan: Tab. Allegra 120 mg stat.\n09:00\r\nS/b Dr Tom\r\nslept well. c/o itching at donor site.\r\notherwise good.\nSeen by Dr.AK.BHat.\r\n5th POstop.day.\r\nItching donor site.Continue trt.Suggested oral antibiotic-moxiflox.\r\n\r\ns/b Dr.nisha\r\nc/o itching at donor site\r\nBP:130/70 pr;80\r\nT moxycip 1 BD\r\ncontinue the same\n09:30\r\nSlept well. FBS - 100mg%\r\ndressings today. GC - fair\r\n\nSeen by Dr.A.K.Bhat.\r\nDressing changed.Donor site and recipient site of SSG clean.Continue trt.\n10:30 AM.\r\nDoing well. Dressing changed yesterday.\r\nAC - 100 mg/dL. Appetite normal.\r\nPassed stools yesterday.\nSeen by DrA.K.Bhat.\r\nContinue trt.\r\n\r\n18:00\r\nGC - fair, Itching decreased. no new complaints.\r\ncontinue same.\n18:30\r\nPt stable. c/o itching at site of surgery. \r\nDressings to be changed tomorrow.\r\ncontinue same.\n9am: S/B Dr. Kenny-\r\nNo new c/o\r\nFair glycemic control.\r\nPlan- Dressings alt. days & ? d/c on Thursday.\n09:00 \r\nDoing well. Itching reduced. \r\nSlept well. c/o excessive hunger intermittently.\r\nInsulin Dose Adjusted.\r\nSeen by Dr.A.K.Bhat.\r\nDressings changed.Clean.\nS/B DrBabu... Patient feels better no complaints, Vitals stable continue same medicines.\n09:00\r\nDoing well. V/S stable. \r\nContinue same.\nSeen by DR.A.K.Bhat.\r\nContinue trt.Plan for discharge tomorrow.\r\n\r\nSeen by Dr.Blessy at 6:40pm\r\nvitals stable\r\ncontinue the same.\n9.45am: s/b Dr. Kenny-\r\nScheduled for Discharge after changing the dressing.\r\nPallor+. Plan check Hb with Prelunch sugar before DC.\nSeen by DR.A.K.Bhat.\r\nDressings chnaged.Rt thigh and leg clean.\r\nAdviced:Change of dressing twice a week.1)Rt thigh-Neosporin powder/jelonet/pad.2)Rt leg-Jelonet/pad/crepe bandage.POP splint at night.Review 2 weeks.""}, {'role': 'model', 'content': '\nIP Number: 503\n\nPatient Number: 6271\n\nAdmission Date: 27-06-2012\n\nDischarge Date: 11-07-2012\n\nDiagnosis: S/P Mid Rt.foot amputation with fasciotomy 1mth back.\n\nClinical Exam(With BP): {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 50yr old male admitted here for skin grafting. Rt mid foot amputation and fasciotomy was done 1 month back.\r\n\\par }\r\n\n\nSystolic BP: 140.0\n\nDiastolic BP: 80.0\n\nPhysical examination: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 \r\n\\par \r\n\\par }\r\n\n\nXray findings: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Temperature   :97.4\r\n\\par Respiration  :22\r\n\\par BP           :140 / 70\r\n\\par Local Examination  :Clean raw areas\r\n\\par }\r\n\n\nDiscussion: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24 50yr old male known case of DM and HTN admitted here for skin grafting.Previously he was admitted here with  c/o Infected wound ulcer in the right leg and fasciotomy was done 1 month back. Now he was readmitted for SSG which was done on 30/06/12. He was put on IV antibiotics and dressings were changed on alternate days. The wound is healing well, with fair glycemic control. He is put on basal bolus regimen for tight glycemic control and will change to pre-mixed Insulin on follow up. Now he is being discharged in a stable state.\r\n\\par }\r\n\n\nDiet: nan\n\nRemarks: 2 hr PPBS post lunch on review date.'}]"
533,"[{'role': 'user', 'content': '\nIP Number: 533\n\nPatient Number: 6831\n\nPatient Name: PAREED M A\n\nGender: M\n\nDate of Birth: 17-07-1954\n\nAddress: VADAKKANETHIL HOUSE, MANJAPETTY\n\nPincode: 683105.0\n\nPhNo: nan\n\nAdmission Date: 17-07-2012\n\nDischarge Date: 06-08-2012\n\nDiagnosis determined by the doctor when the patient was admitted: TYPE 2 DIABETES MELLITUS\nMixed hyperlipidaemia\nDIABETIC FOOT\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: Admitted with gangrene of the 2nd toe Rt foot and ulcer on the plantar aspect of the Big toe RT foot. pt was admitted in AIMS , discharged AMA.\n\nXray information: 13/7/12: HbA1C 10.9%, TSH 1.49, TGL 196, HDL 13.8mg%\r\nECHO (14/07/2012) - WNL.\r\n\n\nClinical examination: General Examination  :CVS-S1 S2 heard\r\nRS- vesicular BS.\r\nAbdomen- soft\r\nLocal-  Rt. Foot gangrenous necrotising, ascending infection of 2nd toe with infected,blackish blister extending to instep area of foot ?ascending synovial infection upto mid leg, with cellulitis.Nonhealing ulcer bigtoe.Distal pulsations not felt ?atherosclerosis.\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: 18:00\r\narterialdoppler done.\r\ntemp-101F,advice to give Tab.Paracetamol.\r\nNow pt feeling better\r\nGRBS-373mg/dl\nSeen by Dr.A.K.Bhat.\r\nRT. FOOT gangrenous necrotising,ascending infection of 2nd toe with infected,blackish blister extending to instep area of foot,?ascending synovial infection upto mid leg,with cellulitis.Nonhealing ulcer bigtoe.Distal pulsations not felt.?atherosclerosis.\r\nPlan:Amputation of 2nd toe and deroofing /faciotomy of foot and leg under SA-tomorrow.\r\nAdviced:Arterial doppler of rt lower limb.IV antibiotics.C&D.Informed consent.Medical fitness for the procedure.\r\nThe bystanders have been explained about the severity of infection and prognosis regarding foot&Wound viability.\n07.45pm\r\nS/B Dr. Raees\r\ndoing well, No complaints\r\nBP-150/80mm of Hg, HR- 84/min, SPO2-98 in room air\r\ncont. same\r\n\r\n09.30 pm\r\nC/O pain at surgery site\r\nBP-150/80 mm of hg, HR- 82/min, SPO2- 97 in room air\r\nINJ. Tramadol 50 mg IM stat\n10:00\r\nPosted for amputation of 2nd toe Rt. with deroofing and fasciotomy of foot and leg.\r\nVitals - normal.\r\nChest - clear.\r\nBlood investigations: WNL.\r\nChest XRay - NAD.\r\nECG - RBBB +.\r\nMedically fit for the surgery.\nSeen by DrA.K.Bhat.\r\nNo soakage.For change of dressing in ICU tmrw.Continue trt.\r\n\r\n\r\nSeen by Dr Blessy\r\nContinue the same.\nVitals stable. post debridement and amputation of the 2nd toe yesterday.\r\nNo pain now.\r\ntransfer to the room\n09:50\r\nFeels tired. Slept well. Not eating well.\r\nFBS - 127mg%. Na+ - 123.\r\nGiven 500 ml NS yesterday.\r\nConsider correcting the Sodium.\nSeen by Dr Blessy\r\nvitals stable\r\nGRBS-169\r\ncontinue the same.\n1030: s/b Dr. Kenny-\r\nVitals normal. Alert\r\nDressing done yesterday.\r\nUrine spot Na / Pus culture report awaited.\r\nFBS : 127mg%.\r\nContinue the same.\r\n\n1800: S/B Dr. Kenny-\r\nPus c/s- Heavy growth of Proteus S Piptaz, Ceftria.\r\nPased stool, GRBS 178mg%.\r\nPlan- cont. same.\n18:00\r\nc/o pain,\r\nadvice to continue same medications,\r\ndressing done today.\nVitals stable.\r\nNa- 128\r\nCreatinine- 0.8\r\nHb- 8.6\r\nTC- 10,800, has not has bowel movemnets .\r\nSeen by DrA.K.Bhat.\r\nChange of dressing done.The rt.3rd toe looks dusky&unhealthy.The big toe mtp joint looks necrotic.No proximal extension of infection to above ankle.Margins of sole wound look unhealthy.Needs probably midfoot amputation after debridement under SA.Plan discussed with bystanders.Plan for the procedure after 2 dressings?.\r\nContinue trt.\r\nOne pint packed cell transfusion.\r\n\r\nSeen by Dr Blessy\r\n\n09:15\r\nCheerful, Passed stools. Transfuse 1 unit PRBC today.\nSeen by DrA.K.Bhat.\r\nContinue trt.\r\n\r\nSeen by Dr Blessy\r\nContinue the same.\r\n\r\n\r\n\nSeen by Dr Blessy\r\nVitals stable\r\nNo complaints\r\ncontinue the same.\nSeen by DrA.K.Bhat.\r\nC&D done.Plan for Midfoot amputation under SA on thursday.\r\n\r\n\r\n09:30 s/p transfusion 1 units of PRBC yesterday, spiked fever yesterday. will dicuss with Dr bhat regarding the change in antibiotic\r\npus culture- proteus\r\n\n1830: s/b Dr. Kenny-\r\nDressing done, Bystanders yet to decide re.amputation.\r\nRpt. Na with Se. Albumin,SGPT & HDL tomorrow AM.\n9.30am: s/b Dr. Kenny:\r\nFeels better, no leg pain,Has numbness Lt.foot. FBS 127mg.\r\nWas transfused 1 unit PRC on Monday. Na had improved to 128 from 123 mEq/L on 22/7/12.\r\nHb improved 10.5gm%, TC decreased 10600/mm3. \r\nDressing today. ?ABx downgrade.\r\n\n10:00\r\nPosted for mid foot amputation today.\r\nGC - fair. pallor +.\r\nHb- 10.6, urea, creatinine- normal.\r\npt medically fit for surgery under spinal anaesthesia\n18:00\r\npt shifted to icu\r\nGRBS-128mg/dl,\r\nBP-170/90MMHG\r\nPULSE-94/MIN\r\nSPO2-99\n09:30 \r\nDoing well. HR - 105/min. Vitals stable.\r\nNo excessive bleeding from the wound. Pt may be shifted to the ward.\nSeen by DrA.K.Bhat.\r\nContinue trt.\r\nGRBS-175mg/dl\n10:30am- s/b Dr. Kenny-\r\nScheduled for dressing today. Afebrile.\r\nnot passed stool for 2 days. No other systemic c/o.\r\nSe. Albumin on 26/7 low-3.2gm%, Na 129, HDL improved, SGPT normal.\r\nPlan- IT works stat, cont. Syp.Looz. \r\nDietician to give Iron rich, high protein diet.\nSeen by Dr.A.K.Bhat.\r\nDressings changed.Ulcers clean.Continue trt.\r\n\r\n1720: s/b Dr. Kenny-\r\nNo new c/o. Started D- protein bd.\r\nCont. all above.\n10:00\r\nGC - better. Afebrile. V/S stable.\r\nSlept well, FBS - 152mg%\r\nChest - clear. Dressing changed yesterday.\nS/B Dr Nisha\r\ngc good,afebrile\r\nO/E chest clear\r\ncontinue the same\n09:40\r\nStable. Dressing change today.\r\nFBS - 136mg%\r\nRpt Hb today. c/o paraesthesia on the arch of Lt foot. \r\nStart Cynocal.\nSeen by DrA.K.Bhat.\r\nC&D done.Clean.Adviced stop inj and start levoflox.\n09:50\r\nHb - 9.0. Plan to transfuse 1 PRBC. \r\notherwise well.\ns/B duty doctor\r\ndoing well,vitals stable\r\ncontinue the same medicine\n10:40\r\nby standers still awaited to donate blood. \r\nFBS - 140mg%. Pallor+.\r\nscheduled for dressing today.\nSeen by DrA.K.Bhat.\r\nC&D done.Clean.\r\n\r\n1815:s/b Dr. Kenny-\r\nNo new c/o, GRBS 140mg%.\r\nPlan- Cont. all above.\r\n\n10:00\r\nslept well. AC - 106mg%. waiting for transfusion.\n18:00\r\ngc-FAIR\r\nBlood transfusion started.\r\nadv-1.Inj.avil 1amp i/m\r\n       2.Inj.lasix 20mg i/v before bloodtransfusion.\nSeen by DrA.K.Bhat.\r\nC&D done.Continue trt.\r\n\r\n\r\nS/B Dr. Raees\r\nPatient Better, no complaints\r\nADV:Continue Same, PLAN for discharge on monday\nVitals stable. slept well. No complaints. S/p transfusion of 1 1unit of PRBC yesterday. sugar well controlled. Dressing change today.\r\nWill check post transfusion Hb , TC\n10 am: s/b Dr. Kenny-\r\nNo new c/o.\r\ndressing done yday.\r\nAwaiting dressing on Monday before d/c.\nSeen by DrA.K.Bhat.\r\nContinue trt.\r\n\r\n1830: s/b Dr. Kenny-\r\nNo new c/o.\r\nPlan- cont. same.\n09:15\r\nhad 2 episodes of vomiting, \r\nAdv: Inj emeset IV stat. , Tab. Axipan 40 mg.\nSeen by DrA.K.Bhat.\r\nPlan for discharge tmrw.\r\n\r\nSeen by Dr Blessy\r\nVitals stable\r\nGC-better\r\n\n09:45\r\nc/o pain and swelling Rt TMJ. \r\nedema +, tenderness +, trismus.\r\nAdv. dental consultation.\r\nTab. Movon 100mg  1-0-1.\r\nChlorhexidine mouth wash.\nSeen by DrA.K.Bhat.\r\nC&D done.SR done.Adviced:Dressing change once in 2 days with betadine oint.and cuticell/pad and bandage.Oral antibiotics for 2 weeks.Review 10 days next wednesday.'}, {'role': 'model', 'content': '\nIP Number: 533\n\nPatient Number: 6831\n\nAdmission Date: 17-07-2012\n\nDischarge Date: 06-08-2012\n\nDiagnosis: s/p Trans metarsal amputation.- Rt foot\r\nAnaemia of chronic disease\n\nClinical Exam(With BP): {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Admitted with gangrene of the 2nd toe Rt foot and ulcer on the plantar aspect of the Big toe RT foot. pt was admitted in AIMS , discharged AMA.\r\n\\par }\r\n\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 ECHO (14/07/2012) - WNL.\r\n\\par }\r\n\n\nXray findings: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 General Examination  :CVS-S1 S2 heard\r\n\\par RS- NVBS\r\n\\par Abdomen- soft\r\n\\par Local-  Rt. Foot gangrenous necrotising,ascending infection of 2nd toe with infected,blackish blister extending to instep area of foot,?ascending synovial infection upto mid leg,with cellulitis.Nonhealing ulcer bigtoe.Distal pulsations not felt.?atherosclerosis.\r\n\\par }\r\n\n\nDiscussion: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24 58 yr old with H/o DM admitted with gangrene of the 2 nd toe RT foot and ulcer on the plantar aspect of the big toe. Pt was started on I.V antibioitcs, Insulin basal bolus regimen for tight glycemic control. seen by surgeon, Amputation of the 2 nd toe with debridement was done on 18/7/12 and due to the underlying infection, a Transmetarsal ampuation was done on 26/7/12. Pt followed with regular dressings. 2 units of PRBC was transfused  for anaemia. Pt discharged under stable condition and asked to follow up as outpt\r\n\\par }\r\n\n\nDiet: nan\n\nRemarks: FBS, 2HR PPBS'}]"
798,"[{'role': 'user', 'content': ""\nIP Number: 798\n\nPatient Number: 8243\n\nPatient Name: SAMKUTTY.V.I\n\nGender: M\n\nDate of Birth: 23-05-1960\n\nAddress: PENIEL HOUSE, PATHANAMTHITTA\n\nPincode: 689649.0\n\nPhNo: nan\n\nAdmission Date: 12-11-2012\n\nDischarge Date: 14-12-2012\n\nDiagnosis determined by the doctor when the patient was admitted: DIABETIC NEPHROPATHY\nDIABETIC  RETINOPATHY\nDIABETIC NEUROPATHY\nTYPE 2 DIABETES MELLITUS\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: h/o scald 3 months ago\r\nnon healing ulcer of Lt heel\n\nXray information: Versa (13/11/12) - Normal arterial study with pressure difference of more than 30mg between the post. tibial and dorsalis pedis in both legs. \r\nVibro (13/11/12) - B/L severe loss of vibratory perception. \r\nTIBC - 273.6ug%, % of Saturation - 18.2%, Iron - 49.8ug%, Folic Acid - 5.1ng/ml. S. Ferritin - 335.7ng/ml, Vit B12 - 1074pg/ml.\r\nECHO (14/11/12) - Normal LV, Mitral annular calcification with mild MR, Aortic sclerosis.\r\nUSG Abd (16/11/12) - No organomegaly, Liver shows mild fatty change. \r\n24hr Urine Protein (20/11/12) - 3.29gm/day\r\nPus C/S (16/11/12) - Heavy growth of Proteus most sensitive to cephalosporins and ofloxacin.\r\nPeripheral Blood Smear (17/11/12) - Normocytic, normochromic anemia (Hb - 10.5gm%) with neutrophil leukocytosis.\n\nClinical examination: ulcer about 3x3 cm over the calcaneum\r\nedges sloping floor filled with granulation tissue minimal pus +\r\nbase onto calcaneum\r\n \n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: s/b duty doctor\r\nvitals stable.dressing with normal saline done\r\ncontinue the same\nSeen by DrA.K.Bhat.\r\nUlcer lt heel at margin.Ulcer clean except for some slough which does not probe to bone.C/S taken.Distal pulsations not felt.Xray no bone involvement.Charcot's.Adviced:Tbact,intrasite gel dressing daily.OFF loading of left heel ulcer area.Continue trt.\r\n\r\n\r\n07.15pm\r\nS/B Dr. Raees\r\nNo complaints\r\nGRBS- 203mg%\r\nContinue same\r\ncase s/b dr jijo\r\ntab Pregaba 75 mg 0-0-1\r\ntab meconerve 1500 mcg 0-1-0\r\nOpthalmology, dental  consultation  tomorrow.\ncase S/B DR Jijo\r\nx- ray showed no bony involvement\r\nadv \r\nto show Dr Bhat \r\ncardiology opinion\r\nto continue same medications\r\n\nAC - 172mg%, Uric Acid - 9.0. Hb - 9.7gm%.\r\ndiabetic bullae on the middle finger.\r\nInj Insugen R 20-20-20. Insugen N 24 HS.\r\nCheck ACR. ECHO today.\nSeen by Dr.A.K.Bhat.\r\nTbact,intrasite gel dressing.\r\n\r\n06.45pm\r\nS/B Dr. Raees\r\nNo complaints\r\nGRBS-282mg%\r\nContinue same\nCASE S/B Dr Jijo\r\nincreased uric acid levels\r\nadv\r\ncontinue same\r\ntab ebuxo 40 mg 0-1-0\r\n\r\ns/b Dr Tom and team. \r\nECHO done yday, AS + mild MR.\r\ns/o Charcot's foot, bounding DP. \r\nFluoresine angiography. \r\nStart Clopidogrel and Tredaptive. \r\n\r\n\r\n\ns/b duty doctor\r\nvitals stable,dressin done\r\ncontinue the same\n07.00pm\r\nS/B Dr. Raees\r\nNo complaints\r\nGRBS-247mg%\r\nContinue same\r\n\r\nS/B Dr Sooraj\r\n-----------------\r\nThanks for referral\r\n\r\nProblems: \r\n1.Type 2 DM\r\n2.Probable Diabetic Nephropathy with Chronic Kidney Disease - elevated creatinine for the past couple of months\r\n3.Diabetic retinopathy\r\nAlready on Losartan\r\n4.has associated CAD\r\nHas depressive illness also\r\nAnemia\r\n\r\nSuggest\r\n---------\r\n1. 24 hr urine protein if the patient is willing.\r\n2. Tab Sobisis 1-1-1\r\n3. Tab Eido 1-0-1\r\n4. requires anemia workup. His MCV was on the lower side earlier but is likely to have associated anemia of chronic disease as he has a non healing ulcer. To do peripheral smear, Iron profile, B12 and folic acid levels and ideally BM ( to look at the BM stores)\r\n5. Oral iron supplementation may be considered\r\n6. Counselling is strongly advised as he is partly depressed and is adamant about not getting investigated, comparing old reports and griping about the treatment and conflicting reports at various centres.\r\n7. He also requires strong dietary counselling and strict diabetic control which he has not been following so far\r\n8. Although all factors are pointing towards a diabetic nephropathy (long standing DM, recent onset hypertension, presence of retinopathy, proteinuria), I would advise a 24 hr urine protein strongly especially in view of albumin creat ratio and urine routine showing conflicting reports. In case 24 hr ueine protein is too low or too high, he will require a renal biopsy.\r\n\r\n\r\n\r\n\n06.50pm\r\nS/B Dr. Raees\r\nNo complaints \r\nFeeling better\r\nContinue same\ns/b Dr Lekshmi mam\r\npt doing better,vitals stable\r\ncontinue the same\nAC - 197mg%, Wt - 89.5kg. \r\nGC - better. dietician to see and advice a fruit to have daily. Yoghurt to be given. \r\ndebridement done today.\nseen by duty doctor 7 50pm\r\npt gc same , no fresh complaints, \r\nvitals stable\nAC - 157mg%. Wound healing well. \r\nMild warmth on the Lt leg. Passed stools. \r\n24 urine protein rpt awaited. Wt - 87.75kg.\nDiscussed the case with Dr sooraj, Advised 0.6mg/kg daily intake and fe supplementation\nEdema better. 24 hr protein in nephrotic range. \r\nprotein restriction.\n08.15pm\r\nS/B Dr. Raees\r\nGRBS- 133mg%\r\nNo complaints\r\nContinue same\nAC - 243mg%, Insulin doses adjusted. \r\nLantus and Ferox XT started. \r\ncontinue rest.\n07.00 pm \r\nS/B Dr. Raees\r\nNo complaints \r\ncontinue same\n07.40pm\r\nS/B Dr. Raees\r\nNo complaints\r\nContinue same\nAC - 212mg%. Case discussed with Dr Jijo. \r\nto decide on flap. \r\nLantus increased to 22 units.\r\ncontinue rest.\nNil special\r\nFBS:169 mg%\r\ncase plan-?for suturing  c/m\r\nTo ct ? oflox\ncase s/b dr Jijo\r\nno sockage\r\nodema+\r\notherwise OK\r\nADV Continue same\nSEEN BY DUTY DOCTOR\r\npt condition same, no fresh complaints ,vitals stable\nSecondary suturing done. AC - 155mg%.\r\nfair glycemic control. \r\ncontinue same.\nAC - 159mg%. strict offloading adviced. \r\ncontinue same.\nseen by duty doctor\r\ng.c same , no fresh complaints, vitals stable\nGC - stable. AC - 128mg%. Creat - 1.8mg%.\r\nDressings changed yday.\r\nPhysio consult for numbness and contracture.\r\ncontinue same.\nAC - 129mg%. no fresh complaints. \r\nmild oozing from dressing site. BP - 130/90.\r\nContinue same. \r\n\nseen by duty doctor\r\npt condition same , no fresh complaints , vitals stable\nDressings changed today.\r\nAC - 124mg%. BP - 130/90.\r\nEdema still present. Continue same.\nseen by duty doctor,\r\npt complains of stuffed nose, no h/o cough, no other complaints\nS/B DR.MANOJ\r\nGC-stable\r\nAC-95\r\nPRE-DINNER-190\nChest - clear, GC - better, wound healing. \r\ndressing change tomorrow. \r\nAfebrile. AC - 124mg%, continue same.\ncase seen by duty doctor\r\n\r\npatient afebrile, vitals stable, \r\nnil special\nAC - 185mg%, Insulin doses adjusted., \r\nContiune same.\ncase seen by duty doctor\r\nvitals stable\nAC - 150mg%. predinner - 161mg%. \r\nNo fresh complaints. \r\nContinue same.\nAC - 136mg%, GC - fair. \r\ncontinue same.\nDressing change today. BP - 130/90. AC - 186mg%.\r\nRpt BRE, RFT. Check GRBS q8h.\r\nContinue same.\nc/o pedal edema\r\nO/E pitting edema\r\nBP:130/80\r\nadviced Tab lasix 1/2 stat\r\ncontinue the same\nGoing to Giridhar for eye consult.\nSEEN BY DUTY DOCTOR\r\nPT COMPLAINS OF NUMBNESS OF THE  LEG, O/E B/L PEDAL EDEMA PRESENT, NO OTHER COMPLAINTS, VITALS STABLE\nGC - much better, wound clean, granulation tissue seen. \r\nAC - 164mg%, slept well. to decide on d/c after one more dressing tomorrow. continue same.\ncase seen by duty doctor  \r\npatient afebrile\r\nvitals stable\r\ncomplaints of rt knee pain\nc/o mild pain in the elbows while supporting weight. \r\nAC - 154mg%, predinner - 137mg%\r\nplan to d/c on friday. plan to discuss rehab with Dr Jijo.\r\ncontinue same.\ncase seen duty doctor\r\nvitals stable\nAC - 110mg%, \r\nplan for d/c tomorrow after planning rehab. \r\nno fresh complaints. Continue same.\nseen by duty doctor\r\npt gc same, complains of increased swellin of left foot,\r\nvitals stable\nd/c today. Stop Cardioplus, Eido, tentral, Evion LC. \r\nGC - fair. Insugen R 28-28-28, Lantus 28 units. \r\ncontinue same.""}, {'role': 'model', 'content': '\nIP Number: 798\n\nPatient Number: 8243\n\nAdmission Date: 12-11-2012\n\nDischarge Date: 14-12-2012\n\nDiagnosis: Charcot Arthropathy Rt- Foot\r\nEcho- MR, AS and Diastolic Dsyfunction\r\n(re)npdr +?csme+(le)pdr +early cataract (be)+pre retinal h.mage (le)\r\nDiabetic Ulcer heel of Lt foot.\n\nClinical Exam(With BP): {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 h/o scald 3 months ago\r\n\\par non healing ulcer of Lt heel\r\n\\par }\r\n\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Versa (13/11/12) - Normal arterial study with pressure difference of more than 30mg between the post. tibial and dorsalis pedis in both legs. \r\n\\par Vibro (13/11/12) - B/L severe loss of vibratory perception. \r\n\\par TIBC - 273.6ug%, % of Saturation - 18.2%, Iron - 49.8ug%, Folic Acid - 5.1ng/ml. S. Ferritin - 335.7ng/ml, Vit B12 - 1074pg/ml.\r\n\\par ECHO (14/11/12) - Normal LV, Mitral annular calcification with mild MR, Aortic sclerosis.\r\n\\par USG Abd (16/11/12) - No organomegaly, Liver shows mild fatty change. \r\n\\par 24hr Urine Protein (20/11/12) - 3.29gm/day\r\n\\par Pus C/S (16/11/12) - Heavy growth of Proteus most sensitive to cephalosporins and ofloxacin.\r\n\\par Peripheral Blood Smear (17/11/12) - Normocytic, normochromic anemia (Hb - 10.5gm%) with neutrophil leukocytosis.\r\n\\par }\r\n\n\nXray findings: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 ulcer about 3x3 cm over the calcaneum\r\n\\par edges sloping floor filled with granulation tissue minimal pus +\r\n\\par base onto calcaneum\r\n\\par  \r\n\\par }\r\n\n\nDiscussion: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24 52 yr old with H/o DM admitted with Uncontrolled blood sugar and non healing ulcer over the Lt heel. and for glycemic control prior to FFA. Routine investigations were sent. Pt was started on basal bolus regimen for tight glycemic control.He was treated at Giridhar eye hospital and given 2 sitting of Pan retinal photo coagulation for PDR. Seen by ortho, Pt had regular dressing and was started on I.V antibiotics, During the stay,Pt had a full comprehensive check up for Diabetes.. Pt had a Nephroconsultation becuase of mildly elevated creatinine and proteinuria. 24 urine for protein was colloected, OHA and meds were adjusted. The wound is healing well and blood sugar levels are with normal limits. Hence discharged in a stable state on oral antibiotics and adviced to do regular dressings. Review in OPD in 1 week time. \r\n\\par }\r\n\n\nDiet: nan\n\nRemarks: nan'}]"
827,"[{'role': 'user', 'content': '\nIP Number: 827\n\nPatient Number: 8506\n\nPatient Name: M PUSHKARAN\n\nGender: M\n\nDate of Birth: 23-11-1938\n\nAddress: MANGALATHU HOUSE, 22 A\n\nPincode: 682020.0\n\nPhNo: 9633874292\n\nAdmission Date: 23-11-2012\n\nDischarge Date: 07-12-2012\n\nDiagnosis determined by the doctor when the patient was admitted: DIABETIC NEPHROPATHY WITH CRONIC RENAL FAILURE\nTYPE 2 DIABETES MELLITUS\nCORONARY ARTERY DISEASE\nEssential (primary) hypertension\nChronic obstructive pulmonary disease, unspecified\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: Admitted for evaluation of Lt lower limb.c/o fever with chills since 2 days .had pain and tenderness lt lower limb at calf level. Symes amputation and stump ulcer+.\n\nXray information: Color Doppler Lt leg (23/11/12) - No e/o thrombosis of deep veins of Lt lower limb is seen, Normal Lt GSV is present at the level of the mid thigh.\r\n\n\nClinical examination: Temperature   :98\r\nRespiration  :22\r\nBP           :120 / 70\r\nWeight       :69.5\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: Seen by DrA.K.Bhat.\r\nSuperf. thrombophlebitis lt leg.Clean ulcers lt foot.Continue trt.XRay lt foot AP&Obl.\r\nECG, PTwith INR\r\nFLPc/m\r\ns/b Dr.manoj\r\nECG-poor progression of r waves\r\n       t wave inversion 1,avl\r\n\r\n\r\n06.45pm\r\nS/B Dr. Raees\r\nC/O pain in Lt lower limb\r\nT. Ultracet 1 HS\r\n\r\nC/O decreased urine output\r\nInj. Lasix 20mg IV stat\r\nCatheterise the patient if output is still less\n07.35pm\r\nS/B Dr. Raees\r\nNo complaints\r\nContinue same\nAC - 233mg%, predinner - 244mg%.\r\nT. Lasix 20mg 1-0-0.\r\nSeen by DRA.K.Bhat.\r\n?subcut. abscess lt leg.GM bd.\npain better.tenderness over achilles tendon+\r\nafebrile.BP110/60 mmHg.\r\n FBS330mg%,\r\nCase plan: inj lantus 30 units HS\r\nInj. actrapid 30-30-30\r\nrpt CBC, KFT c/m. Urine output normal\r\nSeen by DRA.K.Bhat.\r\nNeeds I&D under SA.Pending medical fitness for the procedure and Warf to be stopped.Continue IV antibiotics.GM dressing bd.\nSeen by DrA.K.Bhat.\r\nFor I&D under SA 27th nov.Preop:Consent.Medical fitness for procedure.Betadine scrub.IV antibiotics.\ns/b dr.tom/team\r\nAC-149\r\nplan to give 2 units of FFP TO REVERT PT/INR\r\nTo start inj.vit k 1 amp im od.\nCardio fitness to be given today.\r\nAC - 138mg%. Scheduled for I & D under GA/SA.\r\nBP - 150/80. Afebrile. PR - 100/min.\r\nNebilong and amiodarone added.\nSEEN BY DUTY DOCtor\r\n\r\npt better, no other complaints, vitals stable\nI & D done under GA. uneventful.\r\nAC - 151mg%, BP - 146/80.\r\nGC - better, BP - 76/min. Pain less. \r\nPlan : continue same. Change abx to Biopiper.\nSeen by DrA.K.Bhat.\r\nContinue trt.\r\n\r\nseen by duty doctor\r\ng.c same , no fresh complaints, vitals stable\nCreat - 3.8mg%, Nephro consult. \r\nto decide on PRC after that. Pain less.\r\nGC - much better. AC - 170mg%. \r\nContinue same.\r\n\r\n\r\nS/B DR Sooraj\r\n------------------\r\nDM, DR, DN\r\nPeripheral Vascular disease\r\nAnemia secondary to renal failure\r\n\r\nSuggest:\r\n----------\r\n1. 2 unit packed cells with adequate precautions\r\n2. Serum iron profile, Calcium, phosphorus\r\n3. Peripheral smear\r\n4. Inj RPO 4000 u subcutaneous once a week\r\n5. Tab Sobisis 1-0-1\r\n6. TAb Eido 1-0-0\r\n7. Tab Nefrosave 1-0-1\nSeen by DRA.K.Bhat.\r\nC&D done.Raw area leg clean.Adviced:Change of dressing on 1st saturday with cuticell and oxum gauze.\r\n\r\nseen by duty doctor\r\npt condition good, no fresh complaints, vitals stable\nc/o pain at the surgery site. had a hypo yday. \r\nChest - clear. AC - 142mg%. Insulin doses adjusted. \r\nT. Tramadol 50mg 1 SOS. Stop welset. \r\nInsugen R 25-25-25, Lantus 15 units at b/t.\r\n1 unit PRC given yday. 1 more PRC today. Inj Lasix 20mg IV mid transfusion. \r\nContinue rest.\nseen by duty doctor\r\npt complains of mild cough with expectoration\r\no/e chest clear\ndressing in podiatry.\r\nChange to IV clindamycin. Continue rest.\nseen by duty doctor,\r\npt condition good , no fresh complaints vitals stable\n06.50pm\r\nS/b Dr. Raees\r\nNo complaints\r\nContinue same\ns/b dr.manoj\r\npatient is fine\r\ncough during night\r\nt.levocetrezine 5mg 0-0-1\r\nrest all to continue.\r\nSeen by DRA.K.Bhat.\r\nContinue trt.\nGC - better, TC ~14,000(decreased), Urea - , Creat - 2.7\r\nTo rpt PT/INR. dressing change today. AC - 110mg%.\r\nAfebrile, Cough less. BP - 130/80.\r\nContinue same. To decide on d/c today.\nSeen by DR.A.K.Bhat.\r\nC&D done.Ulcer lt calf region clean.Induration near popliteal region-?residual fasciitis.C/S taken.,.Inj.Clindamycin 600mg  8th hrly.\nChanged the dose of IV Clindamycin to 600mg TID. \r\nAC - 189mg%, had a hypo yPM. Chest - clear. GC - better.\r\nECG & ECHO today. Insulin doses adjusted. \r\nActrapid 20-20-20, Lantus 15 units at bed time. \r\nphysio review. continue rest.\nSeen by DrA.K.Bhat.\r\nInduration decreased.Continue trt/.\r\n\r\ncase seen by duty doctor\r\nvitals stable\nAC - 143mg%, GC - better. Slept well last night.\r\npain and induration better. no more hypos. TC - 14,200.\r\nPlan : continue same.\nSeen by DrA.K.Bhat.\r\nC&D done.Ulcer calf region clean.Induration less.Plan fr discharge on friday.\r\n\r\n\r\ncase seen by duty doctor\r\nvitals stable\nCreat - 2.7mg%, AC - 131mg%.\r\nGC - stable, Slept well. pain and induration better.\r\nPlan for d/c tomorrow. continue same. Dr Sooraj Review.\r\n\r\n\r\nS/B Dr Sooraj\r\n-----------------\r\nRFT much better\r\n\r\nContinue same. review once a month.\r\n\r\nCKD diet - dietician to counsel\r\n\r\n1800 kcal/day, 50 gms proteins.\nSeen by Dr.A.K.Bhat.\r\nContinue trt.Plan fr discharge tmrw,.\nDressing changed yday. AC - 161mg%.\r\nEPO 4000 units given yday. GC - fair, cough better. \r\nAfebrile, Chest - clear.\r\nPlan to d/c today to continue dressing at home on alternate days, basal bolus insulins and oral abx. BP - 150/90.\nSeen by DrA.K.Bhat.\r\nC&D done.Clean.\r\nAdviced:Change of dressing once in 2 days-cuticell/oxum gauze.Oral clindamycin for 10 days.Review 19th wednesday.'}, {'role': 'model', 'content': '\nIP Number: 827\n\nPatient Number: 8506\n\nAdmission Date: 23-11-2012\n\nDischarge Date: 07-12-2012\n\nDiagnosis: Cellulitis Lt Foot\r\nabscess over the lt calf-I&D done under short GA on 28/11.\n\nClinical Exam(With BP): {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Admitted for evaluation of Lt lower limb.c/o fever with chills since 2 days .had pain and tenderness lt lower limb at calf level. Symes amputation and stump ulcer+.\r\n\\par }\r\n\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Color Doppler Lt leg (23/11/12) - No e/o thrombosis of deep veins of Lt lower limb is seen, Normal Lt GSV is present at the level of the mid thigh.\r\n\\par \r\n\\par }\r\n\n\nXray findings: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Temperature   :98\r\n\\par Respiration  :22\r\n\\par BP           :120 / 70\r\n\\par Weight       :69.5\r\n\\par }\r\n\n\nDiscussion: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24 74 yr old male who is ak/c T2DM, CAD , with Symes amputation lt foot was brought in an emergency on 27/11 with c/o fever with chills since the previous night and severe pain lt leg.Clinically at the time of admission,pt was in pain with fever and there was tenderness and edema over the lt calf.There was also astump ulcer over the amputated area,which was clean on inspection.Blood sugars were uncontrolled.Arterial Doppler study of the lt lower limb was wnl.Surgical consult was taken , and he was started on I/V ABs and all supportive treatment was given. Basal bolus insulin was also started.But fever continued , and the abscess over the lt calf was noticed.I&D of the abscess was done on 26/11 under short GA. Since the pt had P/H of CAD with AF , he was on Tab.Warf. He was transfused with 4 pints of FFP prior to surgery in order to correct PT -INR.Platelet transfusion was also given.Nephrology consult for the CRF was done. Inj EPO was given as advised,As the wound was healing well he is being D/d on oral abs with advise to change dressings on alt days.Basal bolus insulins are being contd for the time being.\r\n\\par }\r\n\n\nDiet: nan\n\nRemarks: nan'}]"
1030,"[{'role': 'user', 'content': '\nIP Number: 1030\n\nPatient Number: 9817\n\nPatient Name: PAULSON.K.A\n\nGender: M\n\nDate of Birth: 23-02-1962\n\nAddress: KOCHUMUTTAM, VAZHAKULAM,\n\nPincode: 686661.0\n\nPhNo: 0485 2261116\n\nAdmission Date: 23-02-2013\n\nDischarge Date: 19-03-2013\n\nDiagnosis determined by the doctor when the patient was admitted: DIABETIC NEPHROPATHY WITH CRONIC RENAL FAILURE\nTYPE 2 DIABETES MELLITUS\nDIABETIC FOOT\nDIABETIC PERIPHERAL NEUROPATHY\nEssential (primary) hypertension\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: A known diabetic since ~20 yrs, was earlier managed at Nirmala Medical centre Muvattupuzha for a non healing ulcer in the plantar surface of his Rt foot. Now he is referred here for further evaluation and mgmt. \n\nXray information: ECG (25/02/13) - LVH.\r\nChest X Ray (25/02/13) - CTR normal, Rt dome elevated, Lung fields clear.\r\nVersa (25/02/13) - Normal Lt arterial study with pressure difference of more than 30mmHg b/w the post tibial and dirsalis pedis. Mild Rt arterial ds with pressure difference of more than 30mmHg b/w the post tibial and dorsalis pedis on both sides. Adequate toe pressure. \r\nVibro (25/02/13) - B/L severe loss of vibratory perception. \r\nECHO (25/02/13) - Normal chamber dimensions, No RWMA, Concentric LVH, Normal LV systolic function, Moderate AR.\r\nPus C/S (27/02/13) - Heavy growth of Enterococcus sensitive to \r\nAmpicillin/Cloxacillin, Vancomycin & Cefuroxime.\r\nUSG Abd (18/03/13) - No organomegaly, Liver shows moderate fatty changes, Early benign prostrate hypertrophy present, PVRU - 277ml. \n\nClinical examination: O/E:Large unhealthy ulcer 6x6 cm anterior weight bearing heel,with undermined slough of heel pad.Blisters extending to instep area suggesting subcut. necrosis.Deep pus present in synovial sheath in medial ankle extending above ankle.C/S taken.Dorsal pulsations not felt.Multiple skin rash legs.\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: Admit. Dr Bhat Consultation. CBC, HbA1c, FLP, URE, RFT, S. Elect, LFT, Vibro, ECG, CXR, X Ray Rt foot AP/Obl.\n8.40am\r\nseen by dr tom\r\npatient is fine\r\nlantus changed to 16  U\r\nprelunch blood sugar to be checked and inj actrapid may be changed to 18 U\r\nTab xtor 10 mg to be added.\r\nSeen by DrA.K.Bhat.\r\nNonhealing ulcer rt heel after piercing injury rt foot 1 month ago.Treated in local hospital with slough excision.\r\nO/E:Large unhealthy ulcer 6x6 cm anterior weight bearing heel,with undermined slough of heel pad.Blisters extending to instep area suggesting subcut. necrosis.Deep pus present in synovial sheath in medial ankle extending above ankle.C/S taken.Dorsal pulsations not felt.Multiple skin rash legs.\r\nAdviced:Bring old reports.Xray rt foot &ankle AP&oblique.Versa and Vibro.IV antibiotics continue.\nTC - 24,000, Na - 126, Creat - 2.7, K 3.4, \r\nAC - 180mg%. to discuss on further course of action after being seen by Dr Bhat. \r\nECHO.\r\nSeen by Dr.A.K.Bhat.\r\nPlan:DEbridement,slough excision and fasciotomy rt leg under SA.Preop:Posted for surgery on  26th feb  under SA .\r\nPreoperative Instructions:\r\nGet informed consent.\r\nNil oral as per Anesthetist advice.\r\nClean&dress area on morning of operation.\r\nShave rt leg and betadine scrub ,morning of operation.\r\nIV antibiotics continue.\r\nMedical &Anesthetic fitness for the procedure.\r\n=============\r\nInformed Consent:\r\nThere is infective ulcerative gangrene of right heel with pus and dead tissues extending to heel area and remaining parts of foot.There is also decreased circulation of the leg.Pus is extending deep into leg.Infection may be deep involving bone and joint also.There is diabetes and neuropathy.This infection requires wound cleaning under Anesthesia.The dead tissues of foot and ankle will be removed.During surgery, depending on the findings,extending pus of leg will also be drained by a fasciotomy.After the operation,healing will need observation.Depending on healing further operations may be be needed.Due to diabetes and decreased blood circulation ,wound healing may be delayed.The importance of offloading of the foot during recovery has been explained.The overall recovery and function of the foot will need close observation.The above points have been explained and understood and full consent for operation and anesthesia is given.\r\n\r\nSIGNED. \r\n\nScheduled for debridement today.\r\nphysician fitness given.\r\nAC - 160mg%.\n1 PRC given yday. Hb - 9.1gm%, TC - 29200.\r\nPus C/S report awaited. dressing change tomorrow. \r\nAC - 116mg%. Inj Dalacin Inj Heparin 5000 units. \r\nNeomol infusion q8h. Creat today. \r\n1 more PRC, T. Nitrest. BP - 176/80.\nSeen by DRA.K.Bhat.\r\nContinue trt.\r\n\r\n08.00pm\r\nS/B Dr. Raees\r\nC/O fever\r\nT.welset 500mg 1 stat\r\nContinue same\nAC - 127mg%. Rpt CBC, Creat tomorrow. \r\nDressing change today. Steam Inhalation. \r\nChest - clear.\nSeen by DRA.K.Bhat.\r\nDressings changed.Large raw area foot,ankle and leg.Pus decreased.?Further plan.Continue trt.\r\n\r\n07.40pm\r\nS/B Dr. Raees\r\nC/O fever\r\nInj. neomol IV\r\nContinue same\ndressing changed yday in OT. \r\nAC - 139mg%. \r\nWill decide on course after one more course. \r\nAbx changed to ampoxin and clindamycin.\nHad an episode of fever today morning. \r\nAC - 120mg%. \r\ndressing change today. To discuss with Dr Bhat and decide on further course of action.\nSeen by DrA.K.Bhat.\r\nDressings changed.Large raw area.No pus.\r\nContinue trt.Glucerna powder.Betonin XT.\ns/b dr. radha\r\nAfebrile since yday morning\r\nInj. neomol sos\r\nTo do TC, Hb% ,s.creat c/m\r\nFBS 167 mg%\r\ninj. Lantus 14 units hs\r\nTab. Cardioplus OD\r\nGlucerna-SR 2 scoops BD\r\ndiafoot cream for L/A.\r\nSeen by DR.A.K.Bhat.\r\nContinue trt.\nSeen by DRA..K.Bhat.\r\nDressings changed.Large raw area.Switch over to oral antibiotics.\r\nS/B Dr.Tom\r\n\r\n\nseen by duty dr\r\npt gc same no fresh complaints , vitals stable\n7.15pm\r\nseen by dr jaya\r\nno pain on right leg\r\ncompalints on mild dull aching pain on left leg\nSeen by Dr.Tom and Team\r\nNo fresh complaints\r\nHad food\r\nSlept well\r\nCase plan:\r\nContinue the same.\r\nSeen by DrA.K.Bhat.\r\nPlan for definitive surgery on saturday under SA.\nAC - 98mg%, \r\nplan to d/c on saturday. \r\nNo fresh complaints.  BP - 150/80. \r\nTab. Nebivolol 2.5mg HS.\nSeen by DRA.K.Bhat.\r\nDressings changed.\r\nPlan for definitive stump closure on saturday(9TH march) under SA.\r\n7.15pm\r\nseen by dr jaya\r\nno complaints\r\npain has decreased\nSeen by DR.A.K.Bhat.\r\nContinue trt.Stop heparin.\nTC - 13,600. Creat - 1.7mg%(decreased). \r\nAC - 98mg%. Vitals stable. Afebrile. passed stools. \r\n1 PRC for saturday. Continue same.\nAC - 140mg%. \r\nScheduled for definitive stump closure tomorrow. \r\n\nSeen by Dr.A.K.Bhat.\r\nPosted for proximal foot amputation under SA 9TH March.\r\nPreoperative Instructions:\r\nGet informed consent.\r\nNil oral as per Anesthetist advice.\r\nClean&dress area on morning of operation.\r\nIV antibiotics-MONoscot SB 1.5 gm IV BD..\r\nMedical &Anesthetic fitness for the procedure.\r\n=============\r\nInformed consent\r\nThere is extensive raw area of right foot with exposure of bones of foot.The raw area is of whole sole region extending to ankle and leg.Previous surgery revealed extensive infection including bones.There is diabetes and neuropathy and Charcots foot.The blood supply of the leg is compromised.The raw area treatment options have been discussed.It has been decided to do a proximal foot amputation and cover with foot flap after amputating the toes.After the operation,depending on healing further operations may be be needed.Due to diabetes and decreased circulation,wound healing may be delayed.The overall recovery and function of the foot will need close observation.The importance of offloading and footcare and footwear  in future has been explained.The above points have been explained and understood and full consent for operation and anesthesia is given.\r\n\r\nSIGNED.\nAC - 139mg%.\nprocedure over and shifted to ICU\r\npatient is fully conscious\r\nvitals-stable\r\nchest clear\r\ncombimist neb before shifting to room\r\nHb/pcv/creat tomorrow\n7.15pm\r\ns/b dr jaya\r\npatient is doing fine\r\nno pain/discomfort\r\nBP-120/80\ns/b dr.manoj\r\nHb-10.4/pcv-27/creat-1.4\r\nhad one episode of fever in the morning\r\nC/O mild pain\r\npassed urine /slept well\r\nadv-to cont same\r\nrpt-TC/HB tomorrow\r\nSeen by DrA.K.Bhat.\r\nContinue trt.\nSeen by DrA.K.Bhat.\r\nDRessings changed.Clots evacuated.Viability of dorsoplantar flap needs observation.Continue trt.\r\n7.15pm\r\ns/b dr jaya\r\nhad minimal pain in right leg which subsided following inj tramadol\r\nno other complaints\ndressing to be changed today. 1 more PRC. Hb - 9.4gm%. \r\nintermitent shooting pain. \r\nInj Ampoxin 1-1-1. Will discuss with Dr Bhat regarding DVT prophylaxis.\nHb - 10.5gm%, AC - 154mg%. predinner - 160mg%.\r\nMacraberin 1-0-1. Physio to ambulate without weight bearing on affected foot. Diampimox, LMW dextran x 3. \r\nSeen by DRA.K.Bhat.\r\nContinue trt.Oral antibiotics,.\nc/o constipation 2 days\r\nno abdominal pain,no nausea/vomiting\r\nvitals stable\r\nstart syrup looz 30 ml HS \r\ncontinue the rest\r\n\nSeen by DR.A.K.Bhat.\r\nDressings changed.The flap over heel area was nonviable and hence excised.Raw area clean.Oral antibiotics.\r\n7.30 pm\r\ns/b dr jaya\r\nno complaints\r\nno pain\ns/b dr.tom/co\r\ndoing fine\r\nAC-112\r\nto cont same\nSeen by DRA.K.Bhat.\r\nContinue trt.Withhold Dextran.Restart heparin.\r\n\r\n10:30 AM. \r\ns/b Med Team. \r\nHad a spike of temp yday night. \r\nThe flap was not viable and was excised. \r\nChest - harsh breath sounds. Stop Dextran. \r\nT. lasix 40mg stat. Inj Ceftazidime 1gm 1-0-1. \r\nRestart Varin(Heparin), Chest X Ray. \r\nSteam Inhalation 1-1-1. \r\n\r\n\nAfebrile, no spike since yday. \r\nCXR - Rt mid zone consolidation/?Lower zone collapse. . Chest physio. \r\nRpt TC, Creat. T. Mucolyte\nSeen by DRA.K.Bhat.\r\nC&D done.Plan for discharge monday.\r\n7.15pm\r\ns/b dr jaya\r\npatient has no complaints\r\nafebrile,cough has decreased\r\nvitals stable\nAfebrile, TC ~9000(decreased). \r\nRpt Chest X Ray on Monday. Plan to d/c on monday. \r\nChest physio given. To review. podiatry consult. \r\nLycor for L/A.\r\nSeen by DRA.K.Bhat.\r\nC&D done.Raw area granulating well.Plan fr discharge on monday 18th march.\ns/b duty doctor\r\nc/o oozing from dressing, not blood stained.\r\nAdv:extra padding to dressing.\r\n\n10.20 AM\r\ns/b Dr Biju\r\npatient does not have any complaints.\r\nSeen by DR.A.K.Bhat.\r\nContinue trt.\nS/B Dr Sooraj\r\n-----------------\r\nAcute deteriration in RFT \r\nUrine no active sediment\r\nNot volume overloaded\r\nPassess large volume urine\r\n\r\nSuggest:\r\n\r\n1. USG abdomen with PVRU to rule out a neurogenic bladder\r\n2. Good hydration\r\n3. Continue others\r\n4. Tab Sobisis 1-1-1\r\n7.30pm\r\ns/b Dr Jaya\r\npatient is doing well\r\nno complaints\r\n5. Tab REnolog 1-1-1\r\nurea, creat on 18.03.2013. \r\nWith hold ARBS\nCreat - 5.2mg%, Na - 112mEq/L. Hb - 9.1gm%, \r\nAC - 120mg%. \r\nUSG shows - PVRU - 277ml, Prostrate hypertrophy. \r\nCase Plan - Hypertonic saline. Knell cath. T. Levostra 500mg 1-0-0.\nSeen by DR.A.K.Bhat.\r\nDressings changed.Raw area clean.Adviced:Change of dressing once in 2 days-Jelonet,oxum gauze,pad ,bandage.No weight bearing on right foot.Review 2 weeks.\nCreat - 3.9mg%. GC - better. \r\nT. Veltam 0.4mg 1-0-0. \r\nPlan to d/c today with indwelling catheter. Review after 1 week on wednesday.'}, {'role': 'model', 'content': '\nIP Number: 1030\n\nPatient Number: 9817\n\nAdmission Date: 23-02-2013\n\nDischarge Date: 19-03-2013\n\nDiagnosis: Infected Ulcer Rt foot s/p Debridement.\n\nClinical Exam(With BP): {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 A known diabetic since ~20 yrs, was earlier managed at Nirmala Medical centre Muvattupuzha for a non healing ulcer in the plantar surface of his Rt foot. Now he is referred here for further evaluation and mgmt. \r\n\\par }\r\n\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 ECG (25/02/13) - LVH.\r\n\\par Chest X Ray (25/02/13) - CTR normal, Rt dome elevated, Lung fields clear.\r\n\\par Versa (25/02/13) - Normal Lt arterial study with pressure difference of more than 30mmHg b/w the post tibial and dirsalis pedis. Mild Rt arterial ds with pressure difference of more than 30mmHg b/w the post tibial and dorsalis pedis on both sides. Adequate toe pressure. \r\n\\par Vibro (25/02/13) - B/L severe loss of vibratory perception. \r\n\\par ECHO (25/02/13) - Normal chamber dimensions, No RWMA, Concentric LVH, Normal LV systolic function, Moderate AR.\r\n\\par Pus C/S (27/02/13) - Heavy growth of Enterococcus sensitive to \r\n\\par Ampicillin/Cloxacillin, Vancomycin & Cefuroxime.\r\n\\par USG Abd (18/03/13) - No organomegaly, Liver shows moderate fatty changes, Early benign prostrate hypertrophy present, PVRU - 277ml. \r\n\\par }\r\n\n\nXray findings: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 O/E:Large unhealthy ulcer 6x6 cm anterior weight bearing heel,with undermined slough of heel pad.Blisters extending to instep area suggesting subcut. necrosis.Deep pus present in synovial sheath in medial ankle extending above ankle.C/S taken.Dorsal pulsations not felt.Multiple skin rash legs.\r\n\\par }\r\n\n\nDiscussion: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24 51 yr old with H/o DM, Diabetic Nephropathy admitted with Non healing ulcer over the Rt foot. Started empirically on I.V antibiotics and insulin basal bolus regimen for tight glycemic control.seen by surgeon, debridement of the wound was done  and then later taken up for definitive stump closure ( distal tarsal amputation ), large dorsal  flap with full thickness skin was used to cover the wound, but the flap was excised as it was not taken up. During the stay, he was diagnosed with Rt lower lobe pneumonia., started on Inj fortum and later found to have increase in creatinine, Nephro consulationb was sought, and advised USG abdomen which showed significant  post voidal residual urine . and a foley catheter was placed after which the creatine came down from 5.2 to 3.9. Pt is advised to continue with foley catheter and to follow up with surgery and Nephro  as an outpt\r\n\\par \r\n\\par }\r\n\n\nDiet: nan\n\nRemarks: nan'}]"
1578,"[{'role': 'user', 'content': ""\nIP Number: 1578\n\nPatient Number: 11996\n\nPatient Name: MATHEW A E\n\nGender: M\n\nDate of Birth: 14-07-1948\n\nAddress: ANASSERIL H, CHATHANNOOR\n\nPincode: nan\n\nPhNo: 8943851785\n\nAdmission Date: 14-07-2013\n\nDischarge Date: 08-08-2013\n\nDiagnosis determined by the doctor when the patient was admitted: DIABETIC FOOT\nEssential (primary) hypertension\nPeripheral vascular disease, unspecified\nTYPE 2 DIABETES MELLITUS\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: Patient was admitted in Amritha hospital and was planned for below knee amputation. Came for second opinion.\r\n\r\nCase Plan: Admit, IV abx, Inj Dynalix, Basal bolus insulins. Attempt to salvage as much of the foot as possible in consultation with the surgeon. \n\nXray information: Color Doppler Lt Lower Limb (15/07/13) - Poor arterial blood flow in the Lt femoral artery, Very poor flow in popliteal and anterior tibial arteries. Markedly poor flow with severe dampening of flow in Lt post tibial, peroneal and dorsalis pedis arteries. \r\nECHO (16/07/13) - Dilated LA, No RWMA, Concentric LVH, Normal LV systolic function, Moderate MR, No PAH. (EF - 59%). \r\nS. Ferittin (18/07/13) - 696.9ng/ml. TIBC - 214.3ug/dl. Iron - 27.6ug/dl.\r\nPus C/S (19/07/13) - Heavy growth of MR strain of Klebsiella. \n\nClinical examination: Left lower limb\r\nlateral four toe gangrene \n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: Seen by DRA.K.Bhat.\r\nExtensive infective gangrene lt foot all toes and extending upto ankle.Severe PVD.\r\nPlan:BKA under SA.Repeat Arterial doppler.Medical fitness for surgery.\r\n\r\nS/B Dr Sooraj\r\nThanks for referral\r\n\r\nProblems:\r\nType 2 DM\r\nAcute on CKD\r\nAcute urinary retention\r\nAttempted urinary catheter failed\r\nHad undergone 3 sessions of hemodialysis at Kollam\r\nLast HD on 10th\r\n\r\nNot uremic at present\r\n\r\nAdvice:\r\nUSG shows distended bladder with more than 500 ml of urine. Requires SPC in view of bleeding per urethra and failed second catheter. \r\n\r\nDo urea, creatine tomorrow. \r\nWill plan dialysis if required\r\nTab Trapic 500 mg 1-1-1\r\nContinue antibiotics\r\nHb tomorrow\r\n\n10:20 AM. \r\ns/b Dr Tom and team. \r\nGC - status quo. s/b Dr Bhat yday. \r\nT. Veltam 0.4mg 0-0-1.\nSeen by DRA.K.BHat.\r\nFor Left Below knee amputation 16th July 11AM.\r\nPreop:Nil oral.Informed consent.Medical fitness.C&D.IV antibiotics.Arrange 1 pint packed cells.\r\n==============\r\nInformed consent:\r\nThere is extensive bone,joint and soft tissue infection of left foot upto ankle with gangrene of all toes extending to ankle.There is diabetes and neuropathy and nephropathy.There is reduced circulation of leg from thigh downwards ,as seen in Arterial Doppler report.The extensive and chronic nature of infection makes any form of limb saving operation useless and continued risks for nonhealing and developing recurrence of infection.Hence this requires below knee amputation under Anesthesia.During surgery, depending on the findings,the exact level of amputation will be decided.After the operation,due to diabetes and decreased circulation,wound healing may be delayed.The overall recovery and function of the amputated leg will need close observation.The importance of continuing footcare esp.for the right leg have been explained.Also close medical followup is essential. The above points have been explained and understood and full high risk consent for operation and anesthesia is given.\r\n\r\nSIGNED. \r\n===================\r\n\nS/B Dr Sooraj\r\n-----------------\r\nGood urine output.\r\nUrine clear\r\n\r\nPosted today for BK amputation  under SA\r\n\r\nSuggest:\r\n----------\r\n1. May proceed with the proposed procedure with high risk. Avoid GA. Requires an informed consent regarding post op worsening of renal parameters and HD(in case required)\r\n\r\n2. Avoid over hydration and underhydration. Ideal will be monitoring with CVP\r\n\r\n3. Avoid NSAIDs, amino glycosides and other nephrotoxic agents\r\n\r\n4. Continue others\r\n\r\n5. Urea , creat tomorrow and inform\r\n\r\n6. To start on Tab Renolog 2-2-2 post surgery once oral feeds are allowed.\r\n\r\n\r\n05:09 PM. \r\ns/b Dr Biju.\r\npost BKA, in ICU. \r\nVitals stable. BP - 140/80, HR - 81/min. \r\nSpO2 - 97% in room air. \r\nHad c/o pain. Inj Neomol infusion. \r\n1 PRC transfused. \r\nIVF DNS with 6 units Insugen R to go at 75ml/hr.\n10:23 AM. \r\ns/b Dr Tom/Dr Manoj. \r\nAC - 199mg%, Hb - 7.3gm%, Creat - 4.9mg%, Urea - 94mg%. GC - fair, Afebrile. I/O - 1700/1900ml.\r\n\r\nCase Plan: To initiate upper body exercise with concurrence from Dr Bhat and physio. Foot care by podiatry.\r\n1 more PRC to be transfused today. CBC and Creat tomorrow.\nSeen by DRA.K.Bhat.\r\nNo soakage.Continue trt.\r\n7pm\r\nseen by Dr Jaya\r\npatient is feeling better\r\nno complaints\r\nvitals stable\r\ncontinue same\nS/B Dr Sooraj\r\n-----------------\r\nPost surgery. Doing ok\r\nComplaining of pain at the site\r\nNo lower abdominal pain.\r\nLast creat 4.9\r\nGood uo\r\n\r\nSuggest:\r\n------------\r\n1. Serum iron profile, Calcium, phosphorus\r\n2. Stop Trapic\r\n3. Tab Sobisis 2-0-2\r\n4. Tab Eido 1-0-0\r\n5. Tab Pregabalin 50 mg 1 stat and 0-0-1 ( as a pain modulator. Stop if drowsy)\r\n6. Tab Ultracet 1-0-1\r\n7. Inj Erypro 6000 u subcutaneous once a week\r\n8. Urea, creat on alternate days.\r\n\r\n10:20 AM. \r\ns/b Dr Tom/Dr Lakshmi. \r\nGC - better, c/o pain. AC - 94mg%. \r\nPus C/S - no pathogen isolated. \r\n\r\nCase Plan: Change positions at regular intervals. \r\ns/b Dr Sooraj today morning. \r\nNepro LP at 11AM, 4 PM and at bed time. T. Ultracet 1-1-1.\nSeen by DR.A.K.Bhat.\r\nAfebrile.C&D done.Drain removed.Suture line clean.Continue trt.\n10:38 AM. \r\ns/b Dr Tom and team. \r\nAC - 95mg%. Afebrile. c/o pain esp in the evenings. \r\nCreat - 5.3mg%. Hb - 8.8gm%. Had breakfast. \r\nErypro 6000 units given. Started on T. Lanam by nephro. \r\n\r\nCase Plan: \r\nPhysio to mobilize with concurrence from Dr Bhat. \r\nTo discuss with Dr Sooraj regarding removal of Femoral catheter. Inj Tramadol 1 AMP IV SOS at night. T. Trika 0.25mg 0-0-1. Inj Neomol infusion SOS in the morning for pain.\nSeen by DRA.K.Bhat.\r\nInJ.Lactagard 1.5 gm bd,.Continue trt.1pint packed cell.\r\n7.30PM\r\nseen by Dr Jaya\r\nno complaints\r\nvitals stable\r\ncontinue same\nSeen by DRA.K.Bhat.\r\nC&D done.Suture line clean.Some edema-needs observation.Continue trt.\r\n\r\n10:31 AM. \r\ns/b Dr Tom and team. \r\nCreat - 4.8mg%. Doing well. Pain better but still persistent. \r\n\r\nCase Plan: \r\nStop Ultracet, Inj Tramadol 50mg IV 1-1-1.\r\nContinue same. Abx changed to Biopiper and lactagard.\nSeen by Duty Doctor\r\nGC Better\r\nVitals stable\r\nNil spl\r\nDoing good\nSeen by Dr Anees\r\n\r\nGC good\r\nNo pain\r\nnil spl\r\n\r\nGRBS-297mg/dl at 6pm\r\n\r\nInsugen R-16\r\nInsugen L-18\nSeen by Dr Tom and Dr Anees\r\n\r\nGC good\r\nSlept well\r\nNo pain\r\nPassed stools this morning.\r\n\r\nGRBS-149mg/dl\r\n\r\nCase Plan:\r\nStitch removal presumably on Tuesday\r\n\r\nCBC & RFT tomorrow.\r\nSeen by DR.A.K.Bhat.\r\nContinue trt.\n10:41 AM\r\ns/b Dr Tom and team. \r\nAC - 292mg%. predinner - 297mg%\r\nPain less. Sat up today. Creat - 4.5mg%. TC - 14800.\r\nGC - better. \r\n\r\nCase plan: \r\nInsulin doses adjusted. \r\nInj Insugen R 20-20-20, Inj Insugen N 20 units at bed time s/c. CBC tomorrow. Continue rest. To continue physio.\nSeen by DrA.K.Bhat.\r\nDressings changed.Lateral aspect wound infection-Few lateral sutures removed to drain serosanguinous fluid.Betadine wash given.Continue Inj.Lactagard and Biopiper.\r\n7.30PM\r\nSeen by Dr Jaya\r\nno complaints\r\npatients is doing well\r\nvitals stable\r\ncontinue same\n7.30pm\r\nseen by Dr Jaya\r\npatient is feeling better\r\nvitals stable\r\ncontinue same\nSeen by DRA.K.Bhat.\r\nPain is less.No soakage.Continue trt.\r\n\r\n10:26 AM. \r\ns/b Dr Tom and team. \r\nAC - 281mg%, Hb - 9.8gm%, TC - 15300.\r\nDeveloping a bed sore. \r\n\r\nCase Plan: \r\nIn view of the infection and elevated BSL, to start insulin infusion. Intensify bed care. Physio to continue.\nS/B dr.tom/team\r\nc/o pain in the night\r\ncreat-3.5\r\nac-252\r\n\r\ncase plan\r\nto inspect the wound with surgeon\r\nActrapid 24-24-24\r\nLantus 28 at bedtime\r\nTC/DC/Hb/creat\nSeen by DRA.K.Bhat.\r\nDRessings changed.Edema and redness decreased.Partial sutures removed to drain some seropurulent discharge-C/S taken.Betadine wash given.Suggested InJ.Meropenem.\r\n7.30PM\r\nseen by Dr Jaya\r\nno complaints\r\nvitals stable\r\ncontinue same\n10:47 AM. \r\ns/b Dr Tom and team. \r\nPain less. TC - 15300. AC - 159mg%. BP - 160/110.\r\n\r\nCase Plan:\r\nInsulin infusion for tighter glycemic control. Stop Dynalix. \r\nInj Neoporin 5000 units s/c bd. T. Librium 10mg 0-0-1. \r\nT. Cilacar 10mg 1-0-0.\nSeen by DRA.K.Bhat.\r\nContinue trt.\r\nFor C&D under IV sedation on 26th july.Preop:Consent.Nil oral after 12.30 PM.\n10:20 AM. \r\ns/b Dr Tom.\r\nAC - 230mg%. \r\nScheduled for suture removal under LA. Creat - 2.7mg%\r\n\r\nCase Plan:\r\nInj Lantus 32 units at bed time s/c.\r\nRaise all bolus insulins by 2 units .\r\nErypro 6000 units s/c today.\nS/B DR ANISH\r\nPT CONDITION GUD BP 152/88 \r\nNO OTHER COMPLAINTS\n10:15 AM. \r\ns/b Dr Tom/Dr Lakshmi. \r\nAC - 237mg%. Pain less. Had some sleep. \r\nGC - fair. \r\n\r\nCase Plan: \r\nRepeat TC and Creat tomorrow. Inj Heparin 5000units ? tomorrow after discussing with Dr Bhat. Continue rest.\nseen by dr anish\r\nno fresh complaints vitals good\nSeen by DRA.K.Bhat.\r\nPain decreased.Continue trt.For C&D in OT tomorrow.\r\n\r\n10:50 AM. \r\ns/b Dr Biju/Dr Jaya. \r\nGC - stable. Pain less. AC - 193mg%. \r\nDressing done yday. Creat - 3.5mg%. \r\n\r\nCase Plan: \r\nContinue same t/t. Dressing in OT tomorrow.\n10:01 AM. \r\ns/b Dr Tom. \r\nAC - 131mg%. Hb - 9.5gm%. Creat - 3.1mg%. \r\nPain decreased. GC - better. mild redness on the Rt buttock. \r\n\r\nCase Plan: \r\nC & D in OT today. Silverex oint for L/A. Inj Tramadol 50mg IV before dressing. Lantus 32 uints at bed time s/c.\r\nContinue t/t.\nSeen by DRA.K.Bhat.\r\nDressings of left leg changed.EDema of muscles, but viable.Infection in depth-Thorough betadine saline wash given.Gentamicin instilled.Dreeing done.\r\nAdviced:FFP transfusion.\r\nseen by Dr Jaya\r\npatient is doing well\r\n complaints of leg pain,mild breathing difficulty\r\ninj tramadol 1amp iv stat\r\npropped position\r\noxygen inhalation\r\nsaturation improved\r\ncontinue same\n10:01 AM. \r\ns/b Dr Tom. \r\nAC - 131mg%. Hb - 9.5gm%. Creat - 3.1mg%. \r\nPain decreased. GC - better. mild redness on the Rt buttock. \r\n\r\nCase Plan: \r\nC & D in OT today. Silverex oint for L/A. Inj Tramadol 50mg IV before dressing. Lantus 32 uints at bed time s/c.\r\nContinue t/t.\r\n7.15 am\r\nseen by Dr Jaya\r\npatient is doing well,talking normally\r\nno breathlessness/chest congestion\r\nslept well last night\r\nHR-88/min\r\nBP-148/88(NTG stopped)\r\nsaturation maintained at 95 without oxygen\r\nECG-no fresh changes except for ?deeper Q waves in V6\r\ninformed patient's condition to Dr lakshmi over phone\r\n\r\n10 am (Case seen by Dr. Tom)\r\nPatient well and comfortably resting\r\nHad breakfast\r\nVitals\r\nPR- 93 /mt\r\nBP- 140/80 mm of hg\r\nSPO2- 97%\r\nChest clear\r\nLabs\r\nAC- 203 mg/dl\r\nTrop T - done last night during the distress- positive\r\nCase Plan\r\nTo show Dr. Sasikumar (Cardiologist) and to discuss further Mx of the case\r\nTo continue Mx as ACS\nSeen by DRA.K.Bhat.\r\nNo soakage.Continue trt.\r\nseen by Dr Jaya\r\npatient is doing well\r\n complaints of leg pain,mild breathing difficulty\r\ninj tramadol 1amp iv stat\r\npropped position\r\noxygen inhalation\r\nsaturation improved\r\ncontinue same.\r\n\r\n\r\n8pm\r\nS/B Dr. Jaya\r\nSOB worsened\r\nInj Lasix 40 mg IV stat\r\nO2 2 Lts on flow\r\nInj Pantocid IV 40 mg stat given\r\nSPO2 dropped to 76 %\r\nInformed Dr. Manoj and Dr. Lakshmi\r\nDr. Manoj advised Inj Lasix 40 mg stat (telephonic order)\r\n\r\n8.30 pm\r\nS/B Dr. Manoj\r\nPt dyspnoeic\r\nSPO2 falling\r\nChest- bilateral extensive creps\r\nShifted to ICU\r\n\r\n8.55 pm (ICU)\r\nGasping- SPO2- 45 %\r\nMOnitor showed tachycardia'\r\nPulse- palpable\r\nCyanosis+\r\nAmbu started\r\nIntubation tried\r\nInj Lasix40 mg given\r\nInj Midazolam 1 mg IV stat\r\nReintubated by anesthestist by a bigger tube\r\nConnected to ventilator on SIMV mode\r\nSaturation picked up\r\nMoved to CPAP mode\r\nInj Lasix 40 mg IV stat given\r\nInformed relatives of his condition\r\n\r\n10 pm\r\nextubated\r\nNebulaization with dernide given\r\nCPAP mode given with the mask\r\nNTG started 10 mics started\r\nECG showed new onset LBBB\r\n\r\n11.45 pm\r\nInformed cardiologist\r\nAdvised to give\r\nAsprin 325 mg+ Clopidogrel 300 mg, LMWH, Metoprolol 50 mg+ Tab Nikoran 5 mg+ Statin 40 mg\r\n\r\n\r\n\r\n\r\n8pm\r\nseen by Dr Jaya\r\npatient is resting well\r\nno breathing difficulty/chest discomfort\r\nHR-88/min\r\nBP-144/88\r\nSPO2=96\r\ninformed patient's condition to Dr Tom over phone\r\ncontinue same\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\ncontinue same\r\n\n7.20 am\r\nseen by Dr Jaya\r\npatient is comfortable\r\nno breathlessness\r\nHR-80/min\r\nBP-150/88\r\nSPO2=96\r\ncontinue same\r\n\r\n10:27 AM. \r\ns/b Dr Tom and team. \r\nAC - 285mg%. Vitals stable. SpO2 - 97%. \r\nBP - 150/80. HR - 85/min. GC - much better. \r\n\r\nCase Plan: \r\nTo shift to the room after dressing by Dr Bhat. \r\nChest X Ray before shifting. Increase basal dose of insulins.\r\nIncrease the dose of Lantus 25 units at bed time s/c.\nSeen by DRA.K.Bhat.\r\nDressings changed.Stump muscles look viable and edema is less.Betadine wash given.Gentamicin instilled in deeper space.Continue trt.\r\n\r\n\r\nSeen by Duty Doctor\r\nPt stable\r\nGC better\r\nBP-150/80\r\nGRBS-231mg/dl at 6pm\r\nc/o pain lower limb\r\nInj Tramadol 50mg im stat\nS/B Dr Sooraj\r\n----------------\r\nStable renal functions.\r\n\r\nContinue Sobisis, Renolog and Erypro\r\n\r\n10:20 AM. \r\ns/b Dr Manoj/Dr Lakshmi. \r\nAfebrile. B/P - 150/90. HR - 84/min. \r\nAC - 129mg%, Creat - 3.1mg%, Hb - 9.5gm%. \r\nseen by nephro, Cardio review today. \r\n\r\nCase Plan:\r\nMild pain at the site of the catheter. Continue same. \r\nTo ambulate after concurrence from Dr Bhat with the help of crutches.\nSeen by DRA.K.Bhat.\r\nContinue trt.\r\n\r\nSeen by Duty Doctor\r\nTemp-n\r\nBP-150/90\r\nNil spl,no palpitations\r\nGC good\r\nNo pain\n10:31 AM. \r\ns/b Dr Lakshmi/Dr Manoj. \r\nAC - 117mg%. \r\nSugars dropped down to 91 yday night.\r\nAmbulated by physio today morning. \r\n\r\nCase Plan: \r\nTo continue physio. Continue dynalix. \r\nRpt TC, Creat, S. Elect. tomorrow. \r\nInsulin doses adjusted.\nSeen by DRA,.K.Bhat.\r\nDressings changed.Edema less.No pus.Plan:SSG after 2-3 weeks.Suggested oral antibiotics.URine RE.\r\n\r\n\r\nSeen by Duty Doctor.\r\nc/o pain.\r\nInj Tramadol 50mg im stat\r\nInj Emeset 4mg iv stat\r\nAlso c/o pain during micturition and decreased sleep\r\nCatheter care.\r\nT Trika 0.25mg\n10:52 AM \r\ns/b Dr Tom & team with Dr Bhat. \r\nGC - stable. \r\nAC - 188mg%. physio to ambulate. \r\nContinue same. \r\n\r\nSeen by DRA.K.Bhat.\r\nContinue trt.\nSeen by Duty Doctor\r\nGC-stable\r\nGRBS-6pm-279mg/dl\nSeen by Dr Lakshmi and team\r\nGC-better,slept well\r\nNo pain\r\nTC,Urea,Creatinine coming morning\r\n\r\n\r\n\r\n\r\nSeen by DRA.K.Bhat.\r\nC&D done.Clean.Night POP support slab.Continue trt.\nnil spcl\n10:45 AM. \r\ns/b Dr Tom and team. \r\nCreat - 2.1mg%, GC - much better. \r\nPain less. \r\n\r\nCase Plan:\r\nUro consult tomorrow for ? change of catheter, further course of action. Stop Dynalix. To continue physio to help him sit upright on a chair.\r\nInj Varin 5000 units s/c BD.\nSeen by Dr Saheed/Uro.\r\nCatheter changed to 14 Fr foley.\r\nReview after 4 weeks for catheter change /trial of voiding.\r\nTab.Veltam F OD to be started.\r\nSeen by DRA.K.Bhat.\r\nC&D done.Clean.Continue trt.\r\n\r\n10.46 AM\r\nS/b Dr. Tom and team\r\nGC - better. Afebrile. \r\n\r\nCase Plan: \r\nContinue same. Reduce Insulin by 2 units.\r\nPodiatry care for precious limb. \r\nContinue physio. Continue heparin. \r\nRept Creat, TC and S. Elect tomorrow. \r\nPlan to d/c after 2 more days.\nseen by dranish\r\npt comfortable , no pain, no other complaints\n10:44 AM\r\ns/b Dr. Tom and team\r\n\r\nG/c better\r\nslept well, blood suger well controlled.\r\n\r\nCase plan:\r\nTo discharge tomorrow. beside echo tomorrow before dischage. Nephro consultation tomorrow.\nSeen by DR..AK.Bhat.\r\nContinue trt.\nS/B Dr Sooraj\r\n----------------\r\nCKD stable creat \r\n\r\nanemia \r\n\r\nSuggest:\r\n-----------\r\n\r\nInj Cresp 25 mcg subcutaneous once a week\r\nInj Suffecient 200 mg iv once a week x 5 doses (in 100 ml normal saline over 2 hrs)\r\n\r\nRequires Hep B vaccination.\r\n\r\nInj Engerix B 1ml IM in both celtoids (to repeat at 1,2 , 6 months)\r\n\r\nTab Sobisis 2-0-2\r\nCap Laretol 0.25 mcg 1-0-0\r\nTab Eido 1-0-0\r\n\r\nReviw after 1 month in Nephro OP with urea, creat , HB reports\r\n\r\n10:59 AM \r\ns/b Dr. Tom aand team\r\nFBS-248mm/hg\r\nPre-dinner 264 mm/hg\r\necho done today didnt show any significant changesfrom the previous one. slept well, mild oozing from the wound.\r\n\r\nCase plan:\r\nDischarge today\r\nHep B vaccine \r\nIV iron as adviced by nephro.""}, {'role': 'model', 'content': '\nIP Number: 1578\n\nPatient Number: 11996\n\nAdmission Date: 14-07-2013\n\nDischarge Date: 08-08-2013\n\nDiagnosis: Acute on chronic renal failure s/p BKA.\r\nAcute Cornonary syndrome- new LBBB\n\nClinical Exam(With BP): {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Patient was admitted in Amritha hospital and was planned for below knee amputation. Came for second opinion.\r\n\\par \r\n\\par Case Plan: Admit, IV abx, Inj Dynalix, Basal bolus insulins. Attempt to salvage as much of the foot as possible in consultation with the surgeon. \r\n\\par }\r\n\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Color Doppler Lt Lower Limb (15/07/13) - Poor arterial blood flow in the Lt femoral artery, Very poor flow in popliteal and anterior tibial arteries. Markedly poor flow with severe dampening of flow in Lt post tibial, peroneal and dorsalis pedis arteries. \r\n\\par ECHO (16/07/13) - Dilated LA, No RWMA, Concentric LVH, Normal LV systolic function, Moderate MR, No PAH. (EF - 59%). \r\n\\par S. Ferittin (18/07/13) - 696.9ng/ml. TIBC - 214.3ug/dl. Iron - 27.6ug/dl.\r\n\\par Pus C/S (19/07/13) - Heavy growth of MR strain of Klebsiella. \r\n\\par }\r\n\n\nXray findings: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Left lower limb\r\n\\par lateral four toe gangrene \r\n\\par }\r\n\n\nDiscussion: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24 65 yr old with H/o DM admitted with gangrene of the toes of the Lt foot. Pt was admitted in another hospital with sepsis , acute on chronic renal failure requiring dialysis x 3-4 times, pt was referred to Amritha where they recommended BKA. pt came to our hospital for a second opinion.. Pt was admitted , started on I.V antibiotics, insulin basal bolus regimen for tight control, seen by surgeon. Pt had  hematuria during the insertion of foley catheter, urologist was consulted and catheter was placed under guidance. regular monitoning of the renal function was done. Nephroconsultation was obtained. Pt had transfusion of PRBC, pt had a below knee amputation done on 16/7/13. subsequent dressings there  showed more oozing from the stump, so he was taken up again on 26/7/13 for a revision amputation. 2 days later. pt developed acute resp distress due to acute pulmonary oedema, was shifted to the ICU, was intubated and out on a ventilator, later extubated and put on positive pressure ventilation, clinically imprived after  giving diuretics. Pt had a new LT bundle branch block, was given loading dose of aspirin and clopidogrel and inj LMWH according to creatinine clearence, cardiology consulation was obtained. adjusted the cardiac meds. pt was kept in the ICU for 2 days and shifted later. after that pt clinically improved, labs improved. regular physiotherpay was done. wound got better. pt stable and being discharged to follow up later for SSG to the stump\r\n\\par \r\n\\par }\r\n\n\nDiet: nan\n\nRemarks: nan'}]"
1958,"[{'role': 'user', 'content': '\nIP Number: 1958\n\nPatient Number: 13628\n\nPatient Name: T V NARAYANAN\n\nGender: M\n\nDate of Birth: 29-10-1948\n\nAddress: KARTHIKA, VAIKOM ROAD, TRIPUNITHURA\n\nPincode: nan\n\nPhNo: nan\n\nAdmission Date: 29-10-2013\n\nDischarge Date: 19-11-2013\n\nDiagnosis determined by the doctor when the patient was admitted: DIABETES MELLITUS WITH PERIPHERAL NEUROPATHY\nDIABETIC FOOT\nEssential (primary) hypertension\nPeripheral vascular disease, unspecified\nTYPE 2 DIABETES MELLITUS\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: Patient was admitted with a non-healing stump of right foot (s/p right mid-foot amputation done on 15/9/13).\n\nXray information: nan\n\nClinical examination: Afebrile. \r\nBP - 110/60. \r\nPulse - 70/min. \n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: Case seen by Dr. Robert, \r\nPatient general condition same, no fresh complaints.\r\nTemp: Afebrile\r\n\r\nCase informed to Dr. Lakshmi and advised\r\nAdvice: Tab. Paracetamol 500mg SOS\nSeen by DRA.K.BHat.\r\nUnhealthy rt mid foot amputation stump exposing dessicated and blackish discolored ankle tendons,dessicated tarsal bones,ankle and heel region.Marginal tissues granulating.Distal pulsations not felt.PVD proven.C/S taken.\r\nAdviced:Daily betadine dressings.Offloading.IV antibiotics.Plan:Right Below knee amputation under SA.\r\n\r\ns/b dr.tom\r\ndiscussed the need of BKA with family members\r\nsyp.Looz 30 ml at bedtime\r\n\r\nS/B Dr Anees\r\nnil spl,c/o constipation\r\nVitals stable.\r\n\r\n6pmGRBS-191mg/dl\r\nInformed Dr Laxmi\r\n\r\nInj Actrapid-10\r\nN-8\r\nsyp looz 30ml at bed time\ns/b dr.tom\r\nAC-132\r\nNa-127\r\ncreat-1.3\r\nGC-status quo\r\ncase plan\r\nto show dr.bhatt\r\nto decide on further course\nSeen by DRA.K.Bhat.\r\nPlan fr BKA under SA friday 1st nov 2pm.Daily betadine scrub of leg.Betadine oint.dressing.Medical fitness for operation.IV antibiotics.Arrange 1 pint packed cells.CXR PA,XRay foot AP and lat.Informed consent.Nil oral as per anesthetist.\r\n-----------------------\r\nInformed consent.\r\nThe right foot has been amputated already, in another hospital.The wound is infected and unhealthy and exposing dead bone and unhealthy tissues at amputated level.Infection has spread above ankle to leg also.There is also decreased circulation.There is diabetes and neuropathy.This requires an amputation of the leg at below knee level under anesthesia.Due to diabetes and decreased blood circulation ,wound healing may be delayed.The overall recovery and function of the leg will need close observation.The above points have been explained and understood and full consent for operation and anesthesia is given.\r\n\r\nSIGNED. \r\n==================\r\n\r\n\r\nSeen by Dr. Binu and team\r\nBP - 110/60\r\nAC - 142mg%\r\nhas pain in right side of abdomen.\r\nhe is emotionally upset over the proposed surgery \r\no/e; tenderness in right hypochondriac region\r\n \r\nCase plan:\r\nCounselled patient and family regarding need of amputation and if left untreated, it may cause sepsis. Willing for amputation.\r\n\r\n1 unit PRBC transfusion today\r\n, USG Ab today.\r\nTab X tor 10mg HS\r\nWith hold aspirin\r\nFollow pre Operative orders\r\nKeep one unit PRBC ready tomorrow.\r\nTo get ECho report from Amrita hospital and need evaluation for medical fitness.\r\n\r\n\r\n\r\n\nseen by dr anish\r\npt complains of pain \r\ntab ultracet stat\nSeen by DRA.K.Bhat.\r\nPatient wants operation tomorrow and not today.For BKA tomorrow.Time to be fixed.Rest of the preop. instructions as before.Enema.\nSeen by Dr Anees\r\nPosted for BKA tomorrow\r\n\r\nVitals stable.\r\nGRBS-6pm-198mg/dl\r\nInformed Dr Laxmi\r\nActrapid-10\r\nN-10\r\n\r\nNPO after 6pm\r\nT Axipan HS and CM\r\nT Trika 0.5mg HS and CM\r\nT Emeset HS and CM\nseen by dr anish\r\npt complains of back pain adv t. ultracet stat\r\n11pm\r\npt has difficulty in sleeping and backpain \r\nadv \r\nt trika .25mg stat\r\npactiv infusion stat\nSeen by Dr Biju and Dr Robert.\r\nAC - 91mg%. Na - 124mEq/L. Creat - 0.9mg%. \r\nHb - 11gm%. \r\nBKA done yesterday. Post op uneventful. \r\nc/o LBA. \r\nPus C/S - Moderate growth of MR Strain of Coagulase -ve Staphalococci sensitive to Linezolid, Vancomycin and Doxy. \r\n\r\nCase Plan:\r\nContinue same.\nSeen by Dr.A.K.Bhat.\r\nContinue trt.Tab.Riboflavin.\nSeen by Dr. Tom and team\r\nBP - 110/70mmHg\r\nHb - 11\r\nPt Comfortable\r\nNo socking of dressings\r\n\r\nCase plan:\r\nSyp Looz 20 STAT and HS with 20ml of water.\r\nElevate leg.\r\nBedside physiotherapy.\r\nPodiatry consultation\r\nInj Clexane 0.4 OD\r\nAdded salt and diet\r\nInjActrapid 14-12-12\r\nInj Insugen N -12units at bed tme\r\n\nCase seen by Dr. Robert, \r\n\r\nPatient GC same, no fresh complaints\r\n\r\nAdvice: Continue same medication\nSeen by DrA.K.Bhat.\r\nDressings changed.Drain removed.Suture line clean.Continue trt.\r\n\r\nSeen by Dr. Binu and team\r\nBP - 110/70mmHg\r\n\r\nCase plan:\r\nDulcolax suppository STAT\r\nSyp Looz to continue\r\nTab Crdioplus 1-0-0\r\nNephro LP Powder.\nSeen by Dr. Binu and team\r\nBP - 120/80mmHg\r\nTab Ultracet given\r\n\r\nCase plan:\r\nTo stop Insugen N and start Inj Basalog 16units at bed time.\r\nInj Actrapid 16-14-12\r\nT-bact oinment\r\nTab Calpol 1-1-1\r\nTab Ultracet SOS\r\nTab Ferox XT 1-0-1\r\nTo restart aspirin 75 0-1-0\r\nTo start Physiotherapy.\r\nWait for the deeper culture.\r\nDressing today.\nSeen by DrA.K.Bhat.\r\nContinue trt.Oral antibiotics.\nSeen by Dr. Tom and team\r\nBP - 130/80mmHg\r\n\r\nCase plan:\r\nStop IV antibiotics.\r\nInj Basalog 18units at bed time.\r\nTab Oxicip 500 1-0-1\r\nCetaphil lotion for L/A\nSeen by Dr.A.K.Bhat.\r\nChange of dressing tomorrow.Remov foleys catheter tomorrow.\nSeen by DRA.K.Bhat.\r\nDRessings changed.Clean.Continue trt.Physiotherapy.?Stop dynalix.\r\n\r\nEvening Rounds by Dr. Robert, \r\nPatient GC same, no fresh complaints. \r\nPt. afebrile\nSeen by Dr. Binu and team\r\nBP - 120/60mmHg\r\n\r\nCase plan:\r\nStop Tab Axipan and Tab Calpol.\r\nTab Cynocal M Forte 750 1-0-1\r\nSyp Looz SOS\r\nPosition change.\nSeen by Dr.A.K.Bhat.\r\nContinue trt.\r\n\r\nSeen by Dr. Binu and team\r\nAC - 168mg%\r\nBP - 130/70mmHg\r\n\r\nCase plan:\r\nInj Actrapid 18-16-12\r\nInj Basalog 18units at bed time.\r\n\nseen by Dr Feba,GC GOOD VITALS STABLE\r\nCONTINUE MEDICATIONS\nPatient GC same, no fresh complaints\nS/b Drs/Binu and Robert:\r\n\r\nBetter except constipation.\r\nStable.Sugars fair\r\n\r\nPlan:\r\nCBC, Electrolytes\r\nContinue rest\r\nSyp.Looz SOS\r\n\r\nBinu\nSeen BY DrA.K.Bhat.\r\nDressings changed.Clean.Plan for DC on friday/.\nSeen by Dr. Binu and team\r\nBP - 120/70mmHg\r\nAC - 147mg%\r\nStopped all antibiotics\r\nGC better\r\nBP stable\r\n\r\nCase plan:\r\nDressing today.\r\n\nSeen by Dr. Tom and team\r\nBP - 130/80mmHg\r\nAC - 160mg%\r\nConcerned about not passing stool.\r\n\r\nCase plan:\r\nTab Revera D 1-0-0\r\nContinue rest.\r\n\r\n\nseen by dr anish\r\npt gc better, vitals good\nSeen by DrA.K.Bhat.\r\nAlternate sutures removed.Clean.Plan fr DC on friday.Blood RE tomorrow.\r\n\r\nEvening Rounds by Dr. Robert, \r\nPatient GC same, nil special \r\n\ns/b dr.tom\r\ndoing fine\r\nac-106\r\n\r\ncase plan\r\nsuture removal today\r\nto continue same\nSeen by Dr. Tom and team\r\nAC - 104mg%\r\nBP - 130/70mmHg\r\nGC better\r\n\r\nCase plan:\r\nPlan to discharge tomorrow.\nSeen by Dr Lakshmi, Dr Manoj, Dr Radha.\r\nAC - 84mg%\r\nNo fresh complaints. \r\n\r\nCase Plan:\r\nPlan to discharge today. \r\nPhysiotherapy. \r\nDiabetic Educator for insulin techniques and dose adjustment. \r\nInj Actrapid 16-14-14 units. \r\nInj Basalog 14 units at bed time s/c.\r\nContinue T. Oxcip.\nSeen by DrA.K.Bhat.\r\nSutures removed-healed.Adviced:Change of dressings once in  2days-betadine oint,pad,crepe bandage.Review OP 2 weeks.\nPatient seen\r\nComplaints of constipation\r\nNo other complaints\r\nVitals stable\nSeen by Dr. Tom and team\r\nBP - 130/80\r\nAC - 100mg%\r\n\r\nCase plan:\r\nContinue oral antibiotics.\r\nPhysiotherapist to mobilise with walker.\r\nSerum electrolytes tomorrow.\r\nSeen by DRA.K.Bhat.\r\nContinue trt.\nSeen by DrA.K.Bhat.\r\nContinue trt.\r\n\r\ns/b dr.manoj\r\ndoing fine\r\nAC-101\r\nNo specific compalaints\r\n\r\ncase paln\r\nSyp.Looz 20ml 0-0-1\r\nrest to continue\r\n\nseen by dr anish\r\nno fresh complaints, pt gc good\nSeen by DRA.K.Bhat.\r\nDressings changed.Clean.Adviced:Daily protective dressings betadine oint./pad/crepe bandage.Daily physiotherapy.REview 1 month.\nSeen by Dr. Binu and team\r\nAC- 164mg%\r\nBP- 120/80mmhg\r\nGC better, wound clean.\r\n\r\nCase plan:\r\nInj Actrapid 10-10-10\r\nInj Basalog 14 units at bed time.\r\nGlucerna SR 3 scoops at night.\r\nTab Ecosprin AV 0-0-1\r\nDiabetic educator to consult.'}, {'role': 'model', 'content': '\nIP Number: 1958\n\nPatient Number: 13628\n\nAdmission Date: 29-10-2013\n\nDischarge Date: 19-11-2013\n\nDiagnosis: s/p Right mid-foot amputation done on 15/9/13 (AIMS).\r\nRt BKA (2nd Nov 2013)\r\n\n\nClinical Exam(With BP): {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Patient was admitted with a non-healing stump of right foot (s/p right mid-foot amputation done on 15/9/13).\r\n\\par }\r\n\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Chest X-Ray : WNL. \r\n\\par Pus C/S (02/11/13) - Moderate growth of Coagulase -ve Saphylococci sensitive only on Vacomycin, Linezolid and Doxy. \r\n\\par Tissue biopsy (02/11/13) - Section shows segment of artery with atherosclerotic changes. \r\n\\par ECG (29/10/13) - Normal Axis, Sinus Tachycardia, No ST-T changes.\r\n\\par USG Abd (31/10/13) - GB Calculus and sludge with wall thickening - Cholecystitis. Enlarged Prostate with obstructive changes in the UB. Fatty changes in the liver. \r\n\\par \r\n\\par }\r\n\n\nXray findings: {\\rtf1\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\lang1033\\f0\\fs24 Afebrile. \r\n\\par BP - 110/60. \r\n\\par Pulse - 70/min. \r\n\\par }\r\n\n\nDiscussion: {\\rtf1\\ansi\\ansicpg1252\\deff0\\deflang1033{\\fonttbl{\\f0\\fnil\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\f0\\fs24 65 yr old, Mr Narayanan, a known diabetic and hypertensive, presented with a non healing amputation stump. Since he had a non healing gangrenous ulcer on the Rt foot, a mid foot amputation was done at another hospital. Since the amputation stump was not healing, he was brought here. He was evaluated and preliminary evaluation revealed elevated counts. He was also seen by our podiatric surgeon and was advised AKA/BKA as the stump was beyond salvage. The pt and bystanders were counselled on the gaurded prognosis and future implications and rehabilitative measures possible post AKA/BKA. He underwent Below Knee Amputation on 2nd November 2013 under SA with full aseptic precautions. The post op was uneventful. He was shifted to the room and daily dressings were given. His blood sugars were kept under tight control with basal bolus insulin regimen. Wound was monitored closely and regular dressings were given. Regular physiotherapy was given for ambulation under supervision. He is recovering well and the wound is healing well and he is discharged in a stable condition and advised to review as outpt.\r\n\\par }\r\n\n\nDiet: nan\n\nRemarks: nan'}]"
2413,"[{'role': 'user', 'content': '\nIP Number: 2413\n\nPatient Number: 8836\n\nPatient Name: SUBRAMANIAN.V\n\nGender: M\n\nDate of Birth: 19-12-1955\n\nAddress: 909, SUNNY PALACE, CHANGAMPUZHA\n\nPincode: 682024.0\n\nPhNo: 0484 2535523\n\nAdmission Date: 27-02-2014\n\nDischarge Date: 19-03-2014\n\nDiagnosis determined by the doctor when the patient was admitted: DIABETIC PERIPHERAL NEUROPATHY\nEssential (primary) hypertension\nTYPE 2 DIABETES MELLITUS\nMixed hyperlipidaemia\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: C/O ulcers in the 2nd and 3rd toe of left foot\r\nKnown Diabetic since 27 yrs\r\n\r\nIMP:Diabetic Foot\r\n      Peripheral Neuropathy\r\n      Type 2 Diabetes Mellitus\r\n      Calcinosis Cutis\r\n\r\nCARE PLAN:Admission\r\n                  Plan Kwire fixation for 2nd left toe\r\n                  T-Bact dressing\r\n                  Inj.Monoscot SB 1.5mg IV BD\r\n                  Stop Tab.Glinil M\r\n                  Insugen R 4-4-4 units 1/2 hr before meals S/C\r\n                  Insugen N 4 units At bedtime S/C\r\n                  Continue other medications\n\nXray information: ECG (06/03/14) - Normal Axis, Sinus Rhythm, No ST-T changes. \r\nVersa (06/03/14) - Normal Arterial Study. \r\nVibro (06/03/14) - Rt Mild loss of vibratory perception. \r\nPus C/S (09/03/14) - No pathogen isolated in culture. \n\nClinical examination: GC fair.\r\nSystemic examination :WNL\r\nL/E:Ulcer on 2nd and 3rd toe.ulcer on 2nd toe exposing the PIP joint.\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: seen by Dr.Debasweta at 8:15pm\r\nPatient comfortable.GC fair.Vitals stable.\nSeen by DRA.K.Bhat.\r\ntbact dressings.\r\n-----------------------------------------------------\r\nSeen by Dr.Debasweta at 8pm\r\nPt comfortable.GC fair.Vitals stable.\nSeen by Dr. Lakshmi, Dr. Manoj and Dr. Robert\r\nGC better\r\n\r\nBP - 130/70mmHg\r\n\r\nCase plan:\r\nStop Aldonil\nSeen by Dr Tom and team. \r\nAC - 123mg%. \r\nGC - better, Afebrile. \r\n\r\nCase Plan:\r\nInj Ciptec 200mg 1-0-1. \r\nStop Monoscot SB. \r\nWill plan on 99Tc Scan after discussing with Dr Bhat.\r\nSeen by DRA.K.BHat.\r\nExposed PIP joint of 2nd toe.Tbact dressings.\nseen by Dr.Debasweta at 8:10pm\r\nPt had itching in the left forearm after the first dose of Inj.Ciptec. Inj was administered after test dose.Pt did not develop any reacting after test dose.Otherwise pt is comfortable.Vitals stable.Informed Dr.Biju\r\norders on phone:Stop Ciptect.\r\n           Inj.Monoscot SB 1.5MG \r\n\n\r\nS/B Dr Radha\r\nFBS - 156 mg%\r\nCARE PLAN-\r\nTc bone scan planned for tomorrow\r\ninsugen N 8 units s/c HS\r\ninsugen R 4-6-6 units s/c \r\n\r\n\r\nSeen by DRA.K.BHat.\r\nOptions given :\r\n1)Wait.\r\n2)Bone nibbling and Kwire insertion(with risks of toe loss ending up in toe amputation being explained).\r\nTbact dressings.\nPatient doing well, no fresh complaints. \r\nPatient afebrile. \r\n\r\nCase Plan: Continue the same\nPt seen by podiatrist.\r\n\r\nseen by Dr.Debasweta at 7:35pm\r\nPatient better.GC fair.Vitals stable.\nSeen by Dr. Tom and team\r\nGC better\r\nWound healing\r\n\r\nPain: 1/5\r\n\r\nAC: 158mg/dl\r\nBP: 100/70 mmHg\r\n\r\nCase plan:\r\nPt to be sent 99 TC\r\nIns Insugen R 8-8-8\r\nSeen by DrA.K.Bhat.\r\nContinue trt.\r\nIns Insugen N 8 units at bed time\nSeen by Dr Ajish and team.\r\nFBS - 141 mg%\r\nawaiting  report/advice from orthopaedician based on Tc scan findings.\r\nCare plan - continue the current medications.\r\nSeen by DRA.K.BHat.\r\nContinue trt.\nseen by Dr.Debasweta at  8:40pm\r\nPt is better.GC fair.Vitals stable.\nSeen by DRA.K.BHat.\r\nContinue trt.\r\n\r\n\r\nseen by Dr Akhil\r\ngeneral condition good \r\nno fresh complaints \r\nPR:76/MIN\r\nBP:120/70mmHg\r\nRR:22/MIN\r\nTEMP:afebrile\r\nchest clear\r\ncvs: S1 S2 heard \r\nP/A:soft nontender BS+\nPt seen by popdiatrist. Versalab & Vibrometer done. Versalab -normal.Vibrometer-right leg- mild loss of vibratory perception ,left -normal study.\r\n-----------------------------------------------------------------\r\nseen by Dr.Debasweta\r\nPatient comfortable.GC fair.Vitals stable\ns/b Dr Ajish and team\r\nno new complaints\r\nconsidering k wire fixation by Dr Bhat\r\ncontinue same treatment\r\nSeen by DRA.K.Bhat.\r\nFor Kwire fixation of left 2nd and 3rd toes under SA,7Th March,2PM.Preop:Nil oral.Informed consent.IV antibiotics.C&D tomorrow.Medical fitness.Screening tests.Blood RE,Urea,Creat.LFT,BT,CT,PT,INR.\nPt seen by popdiatrist. Versalab & Vibrometer done. Versalab -normal.Vibrometer-right leg- mild loss of vibratory perception ,left -normal study.\r\n-----------------------------------------------------------------\r\nseen by Dr.Debasweta\r\nPatient comfortable.GC fair.Vitals stable\r\n\r\nSEEN BY DR ANISH\r\nPT VITALS GOOD\r\nPULSE 80\r\nBP 126/78\r\nURINE OUTPUT 600ML\nSeen by DRAKBhat.\r\nContinue trt.\r\nRemove foleys catheter.\r\nSeen by Dr. Radha, Dr. Lakshmi, Dr. Manoj, Dr. Biju and Dr. Aparna\r\n\r\nGC better\r\n\r\nPain score: 1/5\r\nAC:102mg%\r\nBP: 130/80mmHg\r\n\r\nCase plan:\r\nCatheter removal today\nSeen by Dr. Divya \r\n\r\nNo specific complaints\r\nVitals stable\nSeen by DR.A.K.Bhat.\r\nC&D done.2nd toe tip looks dusky.3rd toe viable.Continue trt.Inj.Low molecular weight Dextran 1 pint IV infusion od each in 4 hours,for 3 days.\r\n\r\nCase seen by Dr.Lakshmi\r\nPatient well\r\nSugars well controlled.\r\nCare paln:\r\nDiscuss with Dr.Tom regarding ortho consultation and starting Vit D cal.\nSeen by Dr. Divya \r\n\r\nNo specific complaints\r\n6 PM GRBS - 188 mg/dl\nSeen by DRA.K.Bhat.\r\nAdvice:Continue same treatment.\r\nno specific complaints\nSeen by Dr Tom and team. \r\nGC - better. AC - 138mg%. \r\nWound better. 3rd toe healing well. \r\n2nd toe - gaurded prognosis. \r\nVolume Expanders started yesterday to improve micro-circulation. \r\nPain : 1/5. \r\n\r\nCase Plan:\r\nDressings tomorrow. \r\nS. Calcium, Phosphorus, Albumin, ALP. \r\nInj Insugen R 10-10-10 units \r\nInj Insugen N 10 units at bed time s/c.\nS/B Dr.Rebecca\r\nNo fresh complaints.nil special.\r\npatient comfortable\nSeen by DRA.K.Bhat.\r\nDressings changed.2nd toe-duskiness decreased,3rd toe- clean.Inj.Biopiper 4.5 gm IV bd.Stop monoscot.Continue trt.IV Lomodex 1 more day.\r\n\r\nSeen by Dr Ajish and team. \r\nS. Calcium - 9.9, S. Phos - 2.9. ALP - 153. \r\nWound better. \r\n\r\ncase Plan:\r\nInj Biopiper TZ 4.5gm 1-0-1. \r\nSerum PTH.\nCase seen by Dr.Tom and team\r\nPatient doing well.\r\nSlept well.\r\nNo pain\r\nAC:151mg%\r\nBP:110/70mmHg\r\nCase plan:\r\ncontinue same.\r\nSeen by DRA.K.Bhat.\r\nContinue trt.\nno specific complaints\r\ngeneral condition good\nS/B Dr AKHIL \r\nGC FAIR \r\nVITALS STABLE \r\nTEMP:afebrile \r\nPR:78\r\nBP:120/80\r\nRS:CHEST CLEAR\r\nCVS:S1 S2 HEARD NO MURMUR\r\nNO FRESH COMPLAINTS \r\n\r\n\nSeen by DrA.K.Bhat.\r\nDRessings changed.2nd toe duskiness is less.3rd toe clean.Wounds clean.Continue trt.\r\n-------------------------------------------------------------------\r\nSEEN BY DR.AJISH AND TEAM\r\ncontinue IV antibiotics.discuss with surgeon regarding oral antibiotic.PTH results awaited.\r\n\nCase seen by Dr.Tom and team.\r\nGC - better. \r\n\r\nCase Plan:\r\nContinue same.\nSeen by DrA.K.Bhat.\r\nRedness rt 3rd toe-tbact dressings.Continue trt.\r\nc/s/b Dr. Krishna\r\nno specific complaints\r\nDr.Tom asked for the following investigations\r\ns.calcium , s,phosphorus and s.creatinine to be estimated tomorrow early morning\r\nto start 24 hr urine collection for creatinine,calcium and phosphorus tomorrow\r\n\nSeen by DRA.K.Bhat.\r\nDressings changed.2nd &3rd toe viable.Wounds clean.Suggested oral antibiotics-Xpand.\r\n\r\nSeen by Dr. Radha/Dr. Manoj/ Dr. Biju\r\nGC better\r\nWound clean, both toes looks viable\r\n\r\nPain score: 1/5\r\n\r\nBP:120/70 mmHg\r\n\r\nCase plan:\r\nTab Xpand 625 1-0-1\r\nStop Inj Biopiper\r\n24-urine collecton for Ca, Phosphate on going\r\nConsult rheumatologist to see today\nseen by dr joe. dressing done. No new complaints.\nPt seen No fresh complaints\nSeen by DrA.K.Bhat.\r\nAfebrile.Continue trt.\r\n\r\nCase seen by Dr.Biju.\r\npatient well.\r\nNo fresh complaints\r\nCare plan:\r\n24 hr urine Ca, Ph reports awaited.\r\nContinue same treatment.\nSeen by Dr. Tom and team\r\nGC better\r\n\r\nPain score: 0/5\r\n\r\nBP: 120/80mmHg\r\nAC:\r\n\r\nCase plan:\nSeen by DrA.K.Bhat.\r\nDressings changed.Status quo.Sent two subcut. nodule of calcific deposit rt foot for analysis.Plan fr D/C tomorrow.\nSeen by DRA.K.Bhat.\r\n?plan fr discharge tomorrow.\r\n\r\nSeen by Dr Ajish and team. \r\nAC - 126mg%. \r\nUrinary Ca, Phos report awaited. \r\n\r\nCase Plan:\r\nPlan to discharge tomorrow.\nseen by dr anish\r\nno fresh complaint\nSeen by Dr.Tom and Team\r\nGC good\r\n\r\nFBS:152mg/dl\r\nDischarge today.\r\n\nSeen by DrA.K.Bhat.\r\nDressings changed.\r\nAdviced:Review on friday 21st march OP.Leg elevation.No weight bearing on operated area of left foot.Oral antibiotics 10 days.Other medicines as adviced.'}, {'role': 'model', 'content': '\nIP Number: 2413\n\nPatient Number: 8836\n\nAdmission Date: 27-02-2014\n\nDischarge Date: 19-03-2014\n\nDiagnosis: Calcinosis Cutis.\r\nOsteomyelitis Left 2nd and 3rd toe\r\n to R/O Calcium Pyrophosphate crystals\n\nClinical Exam(With BP): C/O ulcers in the 2nd and 3rd toe of left foot\r\nKnown Diabetic since 27 yrs\r\n\r\nIMP:Diabetic Foot\r\n      Peripheral Neuropathy\r\n      Type 2 Diabetes Mellitus\r\n      Calcinosis Cutis\r\n\r\nCARE PLAN:Admission\r\n                  Plan Kwire fixation for 2nd left toe\r\n                  T-Bact dressing\r\n                  Inj.Monoscot SB 1.5mg IV BD\r\n                  Stop Tab.Glinil M\r\n                  Insugen R 4-4-4 units 1/2 hr before meals S/C\r\n                  Insugen N 4 units At bedtime S/C\r\n                  Continue other medications\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: ECG (06/03/14) - Normal Axis, Sinus Rhythm, No ST-T changes. \r\nVersa (06/03/14) - Normal Arterial Study. \r\nVibro (06/03/14) - Rt Mild loss of vibratory perception. \r\nPus C/S (09/03/14) - No pathogen isolated in culture.\n\nXray findings: GC fair.\r\nSystemic examination :WNL\r\nL/E:Ulcer on 2nd and 3rd toe.ulcer on 2nd toe exposing the PIP joint.\n\nDiscussion: 58 yr old with who is  a known case of diabetes with multiple calicifiactions in b/l lower limbs (?calcinosis cutis)  admitted with redness and swelling of the 2nd and 3 rd digit LT foot.Previously also he was admitted with similar complaints which got treated with IV antibiotics.99Tc MDP bone scan was done and it showed features of osteomyelitis.IV antibiotics were given.Podiatry surgeon removed the infected bone and K-wiring was done on 2nd and 3rd toe.During the stay oin the hospital he developed similar complaint on the right lower limb.It was superficial and the surgeon did local I&D.In view of  hypercalcification  PTH level was done and the levels were elevated..24 hour urine is collected for Calcium and Phosphorous excretion to calculate TmP/GFR and it was normal.patient had received Zolendronic acid injections which caused the secondary hyperparathyroid.Rheumatology consultation had been done and he suggested to rule out calcium pyrophosphate crystal deposits.Podiatric surgeon did an I&D and sent the sample for further investigation.Patient is discharged in a stable state and advised review as outpatient with results.\n\nDiet: nan\n\nRemarks: review after 2 days for dressing\r\n\r\n'}]"
2617,"[{'role': 'user', 'content': '\nIP Number: 2617\n\nPatient Number: 16401\n\nPatient Name: PURUSHAN  P K\n\nGender: M\n\nDate of Birth: 14-04-1942\n\nAddress: H# 3 A1 STAR PARK\n\nPincode: nan\n\nPhNo: 6561474\n\nAdmission Date: 14-04-2014\n\nDischarge Date: 02-05-2014\n\nDiagnosis determined by the doctor when the patient was admitted: nan\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: C/O swelling in left lower limb x 2 months\r\nK/C/O varicose veins\r\n\r\nIMP:?Cellulitis left lower limb\r\n\r\nCare Plan:\r\nAdmission\r\nCBC,RFT,S.Electrolytes\r\nTab.Acuvin 1-0-1\n\nXray information: nan\n\nClinical examination: Pallor+ left lower limb edema+\r\nLocal Examination:redness and raised temp+ skin is stretched and shiny.wound over left foot plantar surface.\r\n\r\nSystemic Examination:WNL\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: S/b Dr Benji\r\nHb:8.4g/dl\r\nVitals stable\r\nNo fresh complaints\r\n\nInformed Lab results to Dr.Biju\nS/b Dr benji\r\nVitals stable\r\nNo fresh complaints\r\nCont. same\nS/b Dr Benji\r\nVitals stable\r\nNo fresh complaints\nS/b Dr Benji\r\nNo fresh complaints\r\nVitals stable\nSeen by Dr. Radha/Dr. Manoj/Dr. Shahin\r\nPain score: 2/5\r\nBP: 130/90mmHg\r\n\r\nCase plan:\r\nContinue same\npt seen by Dr.Farook. C/O mild pain\ns/b Dr Radha \r\nc/o pain\r\notherwise doing fine\r\ncase plan \r\nct same treatment\nSeen by Dr. Radha/Dr. Manoj/Dr. Shahin\r\nGC better\r\n\r\nPain score: 3/5\r\nBP: 130/80mmHg\r\n\r\nCase plan:\r\nPodiatry consultation.\nSeen by Dr.Shahin\r\nC/O Mild pain\r\nPatient stable\nPt fine,no complaints at present\r\n\r\nContinue Medications\nseen by Dr.Deba\r\n\r\nPatient comfortable.GC fair.Vitals stable.\nS/b DR Tom & Dr Benji\r\nSlept well\r\nNo fresh complaints\r\nVitals stable\r\nCont. same\r\n\nSeen by Dr. Ajish and team\r\nGC better\r\n\r\nPain score: 1/5\r\nBP: 130/80mmHg\r\n\r\nCase plan:\r\nPlan to discharge tomorrow\nS/b Dr Benji\r\nNo fresh complaints\r\nvitals stable\r\nCont. same\nSeen by Dr. Ajish and team\r\nGC better\r\n\r\nBP: 140/80mmHg\r\n\r\nCase plan:\r\nPlan to disharge today'}, {'role': 'model', 'content': '\nIP Number: 2617\n\nPatient Number: 16401\n\nAdmission Date: 14-04-2014\n\nDischarge Date: 01-05-2014\n\nDiagnosis: Varicose Veins Rt Leg.\n\nClinical Exam(With BP): C/O swelling in left lower limb x 2 months\r\nK/C/O varicose veins\r\n\r\nIMP:?Cellulitis left lower limb\r\n\r\nCare Plan:\r\nAdmission\r\nCBC,RFT,S.Electrolytes\r\nTab.Acuvin 1-0-1\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: nan\n\nXray findings: Pallor+ left lower limb edema+\r\nLocal Examination:redness and raised temp+ skin is stretched and shiny.wound over left foot plantar surface.\r\n\r\nSystemic Examination:WNL\n\nDiscussion: 72 yr old Mr Purushan, presented to us with a non healing ulcer secondary to varicose veins. He was admitted and seen by our vascular surgeon who advised conservative mgmt with dressings and compression stockings. Dressings were changed frequently and leg kept elevated. He is symptomatically much better now and he is discharged in a stable condition and advised to review as outpt.\n\nDiet: nan\n\nRemarks: nan'}]"
3594,"[{'role': 'user', 'content': ""\nIP Number: 3594\n\nPatient Number: 20685\n\nPatient Name: ANTO PULLOKKARAN\n\nGender: M\n\nDate of Birth: 22-11-1946\n\nAddress: PULLOKKARAN HOUSE\n\nPincode: nan\n\nPhNo: 8593857406\n\nAdmission Date: 22-11-2014\n\nDischarge Date: 13-12-2014\n\nDiagnosis determined by the doctor when the patient was admitted: Essential (primary) hypertension\nMixed hyperlipidaemia\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: Provisional Diagnosis : Essential (primary) hypertension\r\n\r\n\r\nAdmitted with a non healing ulcer on the 3rd toe Lt with gangrene.\r\n\n\nXray information: 68 year old, Mr. Anto Pullokkaran admitted with a non healing ulcer on the 3rd toe Lt foot with gangrene. His BP on admission 180/100mmhg. He was started on antihypertensives and BP monitored. He was started on IV antibitoics. Surgery consultation sought. XRay shows ?OM of residual fragment of MPx bone. C/S taken. Planning for revision operation of 3rd toe stump, bone nibbling and closure under LA.In the meanwhile his Platelet count was seen to be > 8 Lacs /mm3 on routine blood investigation\r\nKeeping in mind a differential diagnosis of MDP , a hematology consult was taken at AIMS and BM aspiration cytology and biopsy were done and the reports of which are awaited. He was started on Tab Hydroxyurea , \r\n\n\nClinical examination: GC Stable \r\nChest - NVBS heard\r\nCVS - S1S2 heard\r\n\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: Inj Lactagard 1.5gm 1-0-1. \r\nT. Betacard 1-0-0. \r\nT. Minipress XL 2.5mg 0-0-1. \r\nX Ray Lt foot AP/Obl. \r\nDr Bhat consultation tomorrow. \r\nCBC, RFT, S. Elect.\r\n\r\n\r\nS/b Dr. Tom\r\nAdvised foot elevation \r\nFLP tomorrow\r\n\r\n\r\nGRBS on admission- 121mg/dl\r\nInformed Investigation results\r\n\r\n\r\nC/o pain\r\nInformed Dr.Biju\r\nAdivised Neomol infusion\r\nBP - 180/100mmHg\r\nTab. Minipress given\nSeen by DRA.K.Bhat.\r\nLeft 3rd toe nonhealing ulcer.XRay ?OM of residual fragment of MPx bone.C/S taken.Plan:Revision operation of 3rd toe stump,bone nibbling and closure under LA.Daily tbact dressing.IV antibiotics.\r\n\r\nSeen by Dr.Lakshmi & Dr.Shahin\r\nBP-150/100\r\nPain score-1/5\r\nCrt-1.7 Urea-31\r\nDiscussed case with Dr.Bhatt and need for bone nibbling,patient to decide\r\n\r\nCase plan:\r\nT.Cilacar 10mg 1/2 stat\r\nT.Stiloz 50 1-0-1\r\nT.bestor 5mg HS\r\nT.Ecospirin 0-1-0(Hold for now,to plan after decision on surgery)\r\n\nS/b Dr. Tom and Team\r\nGC good \r\nplatelets high\r\nno hepatosplenomegaly\r\nBP - 150/80\r\n\r\ncase plan\r\nOphthal check up to look for hypertensive retinopathy\r\nUSG Abdomen\r\nversa/vibro\r\nFT4 TSH\r\nPeripheral smear to look for thrombocytosis\r\nUrine -RE\r\nDr. Emil Consultation\r\n\nSeen by DR.A.K.BHat.\r\nFor nibbling of bone and stump revision of left 3rd toe under LA 25th Nov.at 1.30 PM.Preop:C&D tomorrow.Informed consent for toe amputation.IV antibiotics.\r\n\r\nInformed Dr. Lakshmi\r\nGRBS at 06:00pm - 104mg/dl\nInformed Dr. Lakshmi\r\nGRBS at 06:00am - 102mg/dl\r\n\r\nCase plan:\r\nPosted for revision operation under LA today\r\nBP-160/90 (not taken betacard today)\nSeen by Dr Emil\r\n H/o trauma - Delayed development of gangrene of left 3rd toe. underwent amputation.\r\nh/o post traumatic amputation left 3rd toe ( ? OM),Rt 2nd finger.\r\nEx smoker, Hoarse voice.  No comorbidities.\r\n ESR normal\r\n Other reports WNL except creatinine\r\n Xreay- left 3rd toe - partial amputation.\r\n? erosion rt 1st MTP.\r\n\r\nUric acid\r\nCXray PA view\r\n ANA\r\n Rheumatoid Factor.\nS/b Dr. Ajish and Team\r\nBP - 150/90mmHg\r\n\r\nsevere pain last night\r\ndidn't sleep well\r\n\r\nCase Plan\r\nInj. Pactiv 100ml iv 8th hrly\r\nInj. Tramadol 50 mg iv SOS\r\nContinue rest\r\n\nSeen by DRA.K.Bhat,.\r\nContinue trt.\r\n\r\n\nS/B Dr Ajish/Dr Radha/Dr Lakshmi\r\nBP 140/86\r\nAll vitals stable.\r\nCase plan\r\n\r\nSTOP INJ Lactagard & start T.Oxip500 1-0-1 after discussing with Dr Bhatt.\r\nT.Cilacar 1-0-0\r\nT. Minipress XL 5mg 0-0-1\r\n\r\n\nSeen by Dr Bhat.\r\nDressings changed.Clean.Oral Oxcip.\nC/O Pain\r\nTab. Accuvin stat\ns/b Dr.Tom/team\r\nc/o severe pain \r\n\r\no/e\r\nBP-170/100mmhg\r\n\r\ncase plan\r\nTo consult with Haematologist\r\ncontinue rest\r\n\nSeen by DRA.K.Bhat.\r\nDressings changed.Clean suture line.Continue trt.\nSeen by Dr Tom and team. \r\nGC - status quo. \r\nPain Score - 2/5. (intermittently).\r\nAfebrile. \r\n\r\nCase Plan:\r\nDressings today. \r\nStop Neomol. \r\nT. Acuvin 1-0-1 and 1 SOS in the afternoon. \r\nT. Revera D 1-0-0. \r\nContinue rest.\ns/b Dr.Tom & Dr.Shahin\r\nPatient comfortable\r\n\r\nCase plan:\r\nTo start on T.Hydroxyurea after seeing Dr.Neeraj(Haematologist) at Amrita hospital.\nSeen by DRA.K.BHat.\nSeen by DRA.K.Bhat.\r\nDressings changed.Continue trt.\r\n\r\nS/b Dr. Ajish and Team\r\n? MDS from Amrita. \r\nCase Plan:\r\nBone marrow to plan after suture removal.\r\n\r\n\r\n\nSeen by DRA.K.Bhat.\r\nContinue trt.Plan for Suture removal on saturday.\r\n\r\nS/b Dr Benji\r\nVitals stable\r\nNo fresh complaints\r\ncont. same trt\nSeen by Dr.Ajish & team\r\nBP-140/86mmhg\r\n\r\nCase plan:\r\nContinue same\r\n\r\n\nS/b Dr. Ajish and team\r\nGC stable\r\n\r\nCase Plan\r\nContinue same\nSeen by DRA.K.Bhat.\r\nDressings changed.Clean.Continue trt.\nS/B Dr TOM & Team\r\n\r\nCase plan\r\nS/R After Dr Bhat consult\r\nDischsrge Tomorrow\r\n\nSeen by DRA.K.Bhat.\r\nDressings changed.Clean.Continue trt.\r\n\r\ns/b Dr.Tom\r\ndoing fine\r\n\r\no/e\r\nBP-130/80mmhg\r\n\r\ncase plan\r\nto continue same\r\nplan to send to AMRITA for Bone marrow\r\n\nSeen by DRA.K.Bhat.\r\nSutures removed.Continue trt.\nSeen by Dr Tom and team. \r\n\r\nCase Plan:\r\nContinue same. \r\nTo arrange for bone marrow aspiration tomorrow.\nS/b Dr. Tom and Team\r\nGC stable\r\nslept well\r\nBP - 150/80mmHg\r\n\r\nCase Plan\r\nWaiting for bone marrow reports\nSeen by DRA.K.BHat.\r\nDressings changed.Sutures removed.Continue trt.\nSeen by Dr Ajish and team. \r\nBone aspiration report awaited. \r\n\r\nCase Plan:\r\nBiopsy report to be chased. \r\nMay take one week. \r\nContinue same. \r\nDry dressings.\nS/b Dr. Radha and team\r\ndoing fine\r\n\r\nCase Plan\r\nawaiting bone marrow results\r\n\nSeen by DRA.K.BHat.\r\nDressings changed.Clean and healing.Advice:Dressing change once in 2 days-betadine oint.Review OP after 1 week.\nSeen by DRA.K.Bhat.\r\nAdvice:Dressing once in 2 days-betadine oint.Review OP FRiday 19th dec.\r\n\r\nSeen by Dr Manoj and team. \r\n\r\nCase Plan:\r\nT. Hydroxyuea 500mg alt days for 2 days, then OD to continue. \r\nPlan to discharge today.""}, {'role': 'model', 'content': '\nIP Number: 3594\n\nPatient Number: 20685\n\nAdmission Date: 22-11-2014\n\nDischarge Date: 13-12-2014\n\nDiagnosis: CRF ? Hypertensive\r\nOM 3rd toe left foot.\r\n? Myelo Proliferative Syndrome.\n\nClinical Exam(With BP): Provisional Diagnosis : Essential (primary) hypertension\r\n\r\n\r\nAdmitted with a non healing ulcer on the 3rd toe Lt with gangrene.\r\n\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: Chest X-Ray :\r\n\r\n\n\nXray findings: GC Stable \r\nChest - NVBS heard\r\nCVS - S1S2 heard\r\n\n\nDiscussion: 68 year old, Mr. Anto Pullokkaran admitted with a non healing ulcer on the 3rd toe Lt foot with gangrene. His BP on admission 180/100mmhg. He was started on antihypertensives and BP monitored. He was started on IV antibitoics. Surgery consultation sought. XRay shows ?OM of residual fragment of MPx bone. C/S taken. Planning for revision operation of 3rd toe stump, bone nibbling and closure under LA.In the meanwhile his Platelet count was seen to be > 8 Lacs /mm3 on routine blood investigation\r\nKeeping in mind a differential diagnosis of MDP , a hematology consult was taken at AIMS and BM aspiration cytology and biopsy were done and the reports of which are awaited. He was started on Tab Hydroxyurea. Regular dressings were done and wound healing was monitored. He is symptomatically better and wound is healing well. Hence discharged in a stable condition and advised to review as outpt with pending reports and to follow up with Hematologist, Amrita Hospital for further evaluation and mgmt.\n\nDiet: nan\n\nRemarks: nan'}]"
4355,"[{'role': 'user', 'content': '\nIP Number: 4355\n\nPatient Number: 23609\n\nPatient Name: CHANDRAMATHI\n\nGender: F\n\nDate of Birth: 17-04-1935\n\nAddress: KRISHNA,IRIMBANAM\n\nPincode: nan\n\nPhNo: nan\n\nAdmission Date: 02-06-2015\n\nDischarge Date: 24-06-2015\n\nDiagnosis determined by the doctor when the patient was admitted: Mixed hyperlipidaemia\nTYPE 2 DIABETES MELLITUS\nDIABETIC FOOT\nEssential (primary) hypertension\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: 80YEAR OLD FEMALE CAME TO THE HOSPITAL FOR THE C/O PAIN AND DISCHARGE OF PUS FROM HER AMPUTED LEG, SHE IS A K/C/O  TYPE 2 DM/ HT/ MIXED HYPERLIPIDEMIA/RENAL FAILURE/HYPERKALEMIA/DIABETIC FOOT. \n\nXray information: nan\n\nClinical examination: O/E pt gcs fair\r\nL/E -lt below knee amputed area - presence of pus, swelling around the infected area, tender on touch\r\nCVS- S1 S2 +\r\nRS- B/L AE+\r\nP/A- SOFT\r\nCNS-NFND\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: S/B DR SUNDARI\r\nC/O FEVER- TEMP- 100.9\r\nADVICE TAB DOLONEX ST\nSeen by DRA.K.Bhat.\r\nFor revision amputation/Debridement under SA 4th June 2pm.Preop:Nil oral.Informed Consent.C&D.IV antibiotics.Medical fitness.Preop.screening tests.Packed cell arrange.\r\n------------\r\nInformed consent.\r\nThere is infection and nonhealing of the already amputated stump of left leg.Pus extending to near knee joint.There is diabetes and neuropathy and nephropathy.There is previous history of septicemia and dialysis.There is reduced circulation of leg as seen in Arterial Doppler report.Due to the nature of infection,circulation of leg and the unhealthywound, will actually need amputation at a higher level for definitive result.There is continued risks for developing recurrence of infection.The patient bystanders request for conservative surgery in the form of cleaning at the same level of leg and not a higher level of amputation.During surgery, done under anesthesia,depending on the findings,the infected tissues will be removed.Pus will be drained.After the operation,due to diabetes and decreased circulation,wound healing will be delayed.The overall recovery and function of the amputated leg will need close observation.Also close medical followup is essential. The above points have been explained and understood and full consent for operation and anesthesia(under high risk) is given.\r\n\r\nSIGNED.\nS/B Dr Sooraj\r\n-----------------\r\nThanks\r\n\r\nKnown DM, Acute on CKD - improved, left lower limb post amputation status - infection with sepsis and high sugars. She was advised admssion and treatment at Renai Medicity (intensive glycemic control and source control) 1 week back but did not come for followup. She has been admitted now with stump infection and sepsis. RFTs are better and output is good. She has been planned for revision amputation and glycemic control\r\n\r\nSugars better now.\r\n\r\nSuggest: \r\n1. She is a high risk case for surgery. High risk nature of the case and possible chances of worsening of renal functions (+ Renal Replacement Therapyif required) and npossible chances of intra op crash to be explained. Spinal anesthesia preferred over GA\r\n\r\n2. Continue Sobisis, Alfalog, Lamino HP, Sompraz, Renerve plus, Alfugress, Dytor. Stop Natrise\r\n\r\n3. Avoid NSAIDs, Aminoglycosides, other nephrotoxics. Hydration as per cardiac status. Daily RFTs and electrolytes.\r\nWill review as and when required.\nSEEN BY DR. TOM AND TEAM\r\nC/O: \r\nposted for surgery today\r\nO/E: \r\nchest clear, nvbs,no crepts no edema\r\necho: normal,cardilology fitness obtained.\r\nPULSE: 88; spo2 97\r\nBP:100/70\r\nCVS:\r\nCNS:\r\nRS:\r\nSUGAR PROFILE: PREDINNER:\tFBS:\tPPBS:\r\n\r\nINVESTIGATION FINDINGS:k 4.8,na 141 creat 2, tc 11200,\r\nX-RAY: \r\nECG: \r\nUSG ABDOMEN:\r\n\r\nCASE PLAN:posted for surgery today.\r\nCHANGE OF MEDICATION:\r\nCONSULTATIONS PLANNED:\r\nINVESTIGATION TO BE DONE:\r\n\r\n\ndonation unit no. 987\r\nblood group: o positive\r\ndate of collection: 14.5.15\r\ndate of expiry: 25.6.15\r\nblood transfusion to be started 4. 20 PM\r\n\nblood transfusion on flow\r\nbp 190/90 mmhg\r\nadv :inj lasiv 20 mg iv stat\nSeen by DRA.K.Bhat.\r\nContinue trt.SEEN BY DR. TOM AND TEAM\r\nC/O: mild pain over the amputed site\r\n\r\nO/E:  PT GCS FAIR\r\n\r\nPULSE:94/min\r\nBP:140/70mmhg\r\nCVS:s1s2+\r\nCNS:NFND\r\nRS:BL AE+\r\nSUGAR PROFILE: PREDINNER:\tFBS:139\tPPBS:\r\n APPETITE BETTER\r\nINVESTIGATION FINDINGS:\r\nX-RAY: \r\nECG: \r\nUSG ABDOMEN:\r\n\r\nCASE PLAN:  STOP NOVOMIX \r\nADD INJ INSUGEN R 4-4-4 UNITS\r\nINJ CLEXANE 0.4ML SC OD\r\n\r\nCHANGE OF MEDICATION: CONTINUE THE SAME DRUGS\r\nCONSULTATIONS PLANNED:\r\nINVESTIGATION TO BE DONE:\r\n HB, TC , UREA, CREATININE\r\n\nSEEN BY DR. TOM AND TEAM\r\nC/O: \r\n\r\nO/E: doing well\r\n\r\nPULSE:\r\nBP:\r\nCVS:\r\nCNS:\r\nRS:\r\nSUGAR PROFILE: PREDINNER:\tFBS:\tPPBS:\r\n\r\nINVESTIGATION FINDINGS:\r\nX-RAY: \r\nECG: \r\nUSG ABDOMEN:\r\n\r\nCASE PLAN:continue same\r\nCHANGE OF MEDICATION:\r\nCONSULTATIONS PLANNED:\r\nINVESTIGATION TO BE DONE:\r\n\r\n\nSeen by DR.A.K.Bhat.\r\nContinue trt.\nSEEN BY DR. TOM AND TEAM\r\nC/O: no fresh complaints\r\n\r\nO/E: pt gcs fair\r\n\r\nPULSE:86/min\r\nBP:140/80mmhg\r\nCVS:s1 s2 +\r\nCNS:nfnd\r\nRS:bl ae+\r\nSUGAR PROFILE: PREDINNER:\tFBS:130\tPPBS:\r\n\r\nINVESTIGATION FINDINGS: klebsiella present c/s\r\nX-RAY: \r\nECG: \r\nUSG ABDOMEN:\r\n\r\nCASE PLAN:chnage antibiotic after discussing with dr batt regarding c/s report\r\n\r\nCHANGE OF MEDICATION:\r\nCONSULTATIONS PLANNED:\r\nINVESTIGATION TO BE DONE:\r\nSeen by DRA.K.BHat.\r\nContinue trt.\nSEEN BY DR. TOM AND TEAM\r\nC/O: no fresh cpomplaints\r\n\r\nO/E: \r\ngcs fair\r\nPULSE:84/min\r\nBP:130/80mmhg\r\nCVS:s1s2+\r\nCNS:nfnd\r\nRS:bl ae +\r\nSUGAR PROFILE: PREDINNER:\tFBS:159mg/dl\tPPBS:\r\n\r\nINVESTIGATION FINDINGS:\r\nX-RAY: \r\nECG: \r\nUSG ABDOMEN:\r\n\r\nCASE PLAN:\r\nCHANGE OF MEDICATION: continue the same\r\nCONSULTATIONS PLANNED: nephro review tomorow\r\nINVESTIGATION TO BE DONE:\r\n\r\nSeen by DRA.K.Bhat.\r\nDressings changed.Clean.C/S taken.Plan for myoplasty and secondary suturing under SA on Friday 12th june.Stop Biopiper.Start Tab.Oxcip 250 mg 1-0-1.\nSEEN BY DR. TOM AND TEAM\r\nC/O: \r\nooze from the wound since yesterday \r\nO/E: \r\ngcs fair\r\n\r\nPULSE:86\r\nBP:110/70\r\nCVS:s1s2+\r\nCNS:\r\nRS:bl ae+\r\nSUGAR PROFILE: PREDINNER:\tFBS:203\tPPBS:\r\n\r\nINVESTIGATION FINDINGS:\r\nX-RAY: \r\nECG: \r\nUSG ABDOMEN:\r\n\r\nCASE PLAN: 1unit prbc\r\ntomorow myoplasty\r\nCHANGE OF MEDICATION: contnuie same\r\nCONSULTATIONS PLANNED:\r\nINVESTIGATION TO BE DONE:\r\n\r\n\r\n\r\nSeen by DrA.K.Bhat.\r\nOne pint packed cells transfusion.Dressings changed.Abgel dressing done.Plan for myoplasty and SSG under SA ON 12TH June 2pm.Preop:Nil oral.Consent.IV antibiotics from tomorrow morning Biopiper 2.25 gm.Blood HB, repeat.Arrange packed cell.\r\n\r\n s/b dr sundari\r\n 1 unit PRBC trasfusion- no- 1046 \r\n o + ve\r\n start at 2pm.\r\n s/b dr sundari. d/w dr lakshmi\r\n hb 10.1.\ns/b Medicine Team\r\nplanning for myoplasty today\r\n\r\no/e \r\npulse-80/min\r\nBP-130/70mmhg\r\nChest-clear\r\ncvs s1s2+\r\n\r\ncase plan\r\nmay be taken up for surgery with high risk consent\nSEEN BY DR. & TEAM\r\nGC:STABLE\r\nPain score: 1/5\r\nMyoplasty done yesterday\r\nFBS:183 mg/dl\r\nPre dinner: 118 mg/dl\r\nCASE PLAN:\r\nContinue same\r\nStopped welset, gelusil, tramadol, salbutamol nebulization\r\nCt rest\r\nSeen by DRA.K.Bhat.\nSEEN BY DR. TOM AND TEAM\r\nC/O: \r\n\r\nO/E: \r\n\r\nPULSE:\r\nBP:\r\nCVS:\r\nCNS:\r\nRS:\r\nSUGAR PROFILE: PREDINNER:\tFBS:\tPPBS:\r\n\r\nINVESTIGATION FINDINGS:\r\nX-RAY: \r\nECG: \r\nUSG ABDOMEN:\r\n\r\nCASE PLAN:\r\nCHANGE OF MEDICATION: Lantus - 2 units bed time\r\nCONSULTATIONS PLANNED:\r\nINVESTIGATION TO BE DONE: Hb, urea, creatinine, on tuesday\r\n\r\nSeen by DRA.K.BHat.\r\nContinue trt.\r\nTab.Oxcip 250 mg 1-0-1 from tomorrow.\nSEEN BY DR. TOM AND TEAM\r\nC/O: no fresh complaints\r\n\r\nO/E:pt gcs fair \r\n\r\nPULSE:90\r\nBP:140/90\r\nCVS:s1s2+\r\nCNS:nfnd\r\nRS:bl ae+\r\nSUGAR PROFILE: PREDINNER:\tFBS:174\tPPBS:\r\n\r\nINVESTIGATION FINDINGS:\r\nX-RAY: \r\nECG: \r\nUSG ABDOMEN:\r\n\r\nCASE PLAN:\r\nCHANGE OF MEDICATION: CONTINUE SAME\r\nCONSULTATIONS PLANNED:\r\nINVESTIGATION TO BE DONE:\r\nURINE RE SEND\r\nHB, UREA, CREAT ON TUESDAY MORNING,\r\nSeen by DRA.K.Bhat.\r\nDressings changed.SSG taken up.DRain removed.\nSeen by DrA.K.BHat.\r\nContinue trt.?Plan for D/C tomorrow.Remove foleys catheter.\r\n\r\n SEEN BY DR AJISH & TEAM\r\nGCS:STABLE\r\nPREDINNER:268\r\nFBS:140\r\nPPBS:\r\nCASE PLAN:\r\nSTART INJ QRON 200 MG IN 100 ML NS OVER 1 HR &\r\n START INJ CRESP 40MCG  STAT S.C.\r\n\nSEEN BY DR. LAKSHMI & TEAM\r\nGC:STABLE\r\nFBS:145MG/DL\r\nPPBS:\r\nBP-150/70 MMHG\r\nCASE PLAN:occasional clamping of catheter to be done\r\nCONTINUE SAME\r\nSeen by DRA.K.Bhat.\r\nContinue trt.\nSEEN BY DR. TOM AND TEAM\r\nC/O: \r\nno fresh complaints\r\nO/E: gcs fair\r\n\r\nPULSE:88\r\nBP:110/70\r\nCVS:s1s2+\r\nCNS:\r\nRS:bl ae +\r\nSUGAR PROFILE: PREDINNER:\tFBS:\tPPBS:\r\n\r\nINVESTIGATION FINDINGS:\r\nX-RAY: \r\n\r\n\r\nCASE PLAN:\r\ncontinue same treatment\r\ni.v iron today.\r\n\r\nCONSULTATIONS PLANNED: nephro review done today, adviced to continue same.\r\n\r\nSeen by DRA.K.Bhat.\r\nDressings changed.SSG taken up.Continue trt.\r\n\nSEEN BY DR. TOM & TEAM\r\nGC:STABLE\r\nappetite better\r\nPRE DINNER:254 mg/dl\r\nFBS:182 mg/dl\r\nPPBS: mg/dl\r\ncr-2.3\r\nhb:9\r\nurea :71\r\nBP:130/70 mm hg\r\nCASE PLAN:bladder washes given yestrday\r\ninj quron 200 mg in 100 ml ns to be given slowly over 2 hrs\r\ncatheter out on monday\r\nCONTINUE SAME\r\n\r\nSeen by DRA.K.Bhat.\r\nDressing changed.Clean.Continue trt.Remove foleys cathetre.\nSEEN BY DR. & TEAM\r\nGC:STABLE\r\nFBS:\r\nPPBS:\r\nCASE PLAN:\r\ninj quron tomoroww due\r\n remove urinary catheter after self void sensation.\r\nSeen by DRA.K.Bhat.\r\nContinue trt.\nSEEN BY DR. TOM & TEAM\r\nGC:STABLE\r\nPRE DINNER:\r\nFBS:\r\nPPBS:\r\nBP:160/60 mm hg\r\nCASE PLAN:continue same.do pre dinner today & fasting tommorow.cathether removed yestrday.pt has bladder sensations.pt is voiding urine.\r\nplan for discharge day after tomorrow\r\n\r\nSeen by DRA.K.Bhat.\r\nDressings changed.Clean.Plan fr D/C wednesday.\nSEEN BY DR. TOM AND TEAM\r\nC/O: \r\n\r\nO/E: \r\n\r\nPULSE:\r\nBP:\r\nCVS:\r\nCNS:\r\nRS:\r\nSUGAR PROFILE: PREDINNER:\tFBS:\tPPBS:\r\n\r\nINVESTIGATION FINDINGS:\r\nX-RAY: \r\nECG: \r\nUSG ABDOMEN:\r\n\r\nCASE PLAN: contine same. discharge tomorrow.\r\nCHANGE OF MEDICATION:\r\nCONSULTATIONS PLANNED:\r\nINVESTIGATION TO BE DONE:\r\n\r\nSeen by DR.A,.K.BHat.\r\nPlan fr D/C tomorrow\nSEEN BY DR. lakshmi\r\nGC:STABLE\r\nPRE DINNER:\r\nFBS:\r\nPPBS:\r\nBP:110/80 mm hg\r\nCASE PLAN: plan for discharge today\r\n\r\nSeen by DrA.K.Bhat.\r\nDressings changed.Sutures removed.SSG clean.\r\nAdvice:Change of dressing once in 2 days-Betadine oint, Cuticell,pad,crepe bandage.Diafoot cream to thigh.Limb exercises.Review 2 weeks.\nseen Byu DR Lakshmi,\r\nB.P- 170/80\r\nSugar ffairly controlled on Basal bolus regimen.\r\nPt slept well.\r\nNo urinary incontinence\r\n\r\nPlan- INJ Qron 200mg I.V last dose\r\nInj Cresp to be given\r\nDischarge after seen by Dr BHat'}, {'role': 'model', 'content': '\nIP Number: 4355\n\nPatient Number: 23609\n\nAdmission Date: 02-06-2015\n\nDischarge Date: 24-06-2015\n\nDiagnosis: Anaemia of chronic disease\n\nClinical Exam(With BP): C/O PUS DRAINING FROM HER LT AMPUTED LEG\r\nC/O SWELLING / PAIN  AROUND THE AMPUTED AREA\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: nan\n\nXray findings: O/E pt gcs fair\r\nL/E -lt below knee amputed area - presence of pus, swelling around the infected area, tender on touch\r\nCVS- S1 S2 +\r\nRS- B/L AE+\r\nP/A- SOFT\r\nCNS-NFND\n\nDiscussion: 80yr old female has been admitted with blackish discoloration and  drainage of pus from the amputed stump of left limb.Amputation was  done 3 weeks back in Renai Medi-city ,post operatively she had NSTEMI and  refractory pulmonary edema for which she was dialysed . .Wound was improving but the problems started 2 days back and reviewed  with the surgeon in Renai Medi city and was advised admission.But didnt get admitted there and came here for plastic surgery opinion.\r\n    She was earlier been referred by us to Renai Medi City in view of Septicaemia and acute renal failure.Case was seen by the podiatry surgeon and advised revision amputation for which the patient party was not willing,hence wound exploration was planned and was done.The sutures were removed and the necrosed area was excised,daily dressings were done by  the surgeon.The wound was healthy and myoplasty was done later.Patient was given anti-biotic coverage and other supportive care during the hospital stay.Pre-insulin regimen is changed to basal-bolus for better glycemic control.\r\n      Nephrology follow up was done by Dr.Sooraj(Renai Medi-city) and IV Iron and erythropoeitin was given according to his advise.Renal parameters were regualrlly monitored.Cardiology evaluation had been done prior to the surgery.\r\nECHO showed fairly normal LV function.\r\n   Patient improved symptomatically and the wound was healthy,hence planned for discharge \r\n\r\n\n\nDiet: nan\n\nRemarks: If You experience  palpitations, nervousness, sweating, shivering, shakiness, blurred vision, confusion, unconsciousness.\r\nImmediately eat/drink something that contain direct sugar (glucose tab, ½ glass juice, candies) if symptom continue, call your Doctor\r\n\r\nChange of dressing once in 2 days-Betadine oint, Cuticell,pad,crepe \r\ncream to thigh.Limb exercises.\r\nSMBG\r\nMaintain LOGBOOK\r\n\r\nreview  after 2 weeks in Medicine/Podiatry OP\r\n'}]"
7154,"[{'role': 'user', 'content': '\nIP Number: 7154\n\nPatient Number: 32044\n\nPatient Name: P V MARY\n\nGender: F\n\nDate of Birth: 01-07-1948\n\nAddress: KUPPIYANKAL HOUSE\n\nPincode: nan\n\nPhNo: nan\n\nAdmission Date: 09-08-2017\n\nDischarge Date: 28-08-2017\n\nDiagnosis determined by the doctor when the patient was admitted: TYPE 2 DIABETES MELLITUS\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: Patient was admitted with gangrene little toe of right foot.\n\nXray information: nan\n\nClinical examination: pallor - +\r\nRS- NVBS\r\nCVS- S1 S2 heard\r\nAbdomen- soft\r\nEXT- gangrene of the 5 th digit , abscess extending from the plnatar aspect of the 5 th digit to almost the mid foot and also the base of the 4 th digit\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: GRBS at 5.30 pm high informed to Dr.Lakshmi adv to give insugen R 10 units\ngrbs at 7 pm 410mg/dl informed to Dr.Lakshmi and adv to give insugen R 8 units\r\nbiopiper 2.25 gm iv 1-1-1\r\nNS IV fluids on maintanence\nGRBS at 6 am 224 informed to Dr.Lakshmi adv to give insiugen R 6 units.\r\nSeen by DRA.K.Bhat.\r\nFor rt little toe amputation and foot I&D,Debridement under SA.10th aug, 1pm.\r\nPreop:Nil oral.Informed written consent.Medical fitness.IV ABx.C&D.1 unit packed cells.\r\n===================\r\nInformed consent.\r\nThere is extensive pus filled infection of right foot extending from gangrenous dead little toe upto ankle region.This pus infection is extending to the region of other toes,possibly upto bone and joint.The other 4 toes are pale and cold suggesting compromise in circulation of these toes also.There are multiple pus filled blisters in this region of foot and on dorsum of foot also.There is diabetes and neuropathy and nephropathy and decreased circulation of leg.The infection of foot needs incision and drainage and slough excision under anesthesia.During operation, the spreading infection will be opened up and dead and necrotic skin and soft tissues will be removed.The dead little toe will be removed.In diabetes, the initial wound will be small,but spreading infection will extend below the skin and hence after surgery, the wound will be larger than the present wound.Due to diabetes and decreased circulation,control of infection and healing will be delayed.Repeat surgery may be needed.Due to extent of infection, the healing and circulatory condition of other 4 toes will need observation.Understanding the above, consent for anesthesia and operation is given.\r\n=====================\nSEEN BY DR.  TOM       &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:pain right foot\r\nFBS:224     MG/DL\r\nCASE PLAN :\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nSEEN BY DR. TOM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:PAIN over the surgery site\r\nPAIN SCORE:2/5\r\nFBS:242     MG/DL\r\nIntake /output-1600/1300\r\nCASE PLAN :\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\nSeen by DRA.K.Bhat.\r\nContinue trt.Repeat FBS,Urea,Creat,Hb,TC tmrw.\nSeen by DRA.K.BHat.\r\nContinue trt.\r\nSEEN BY DR.Tom\r\nPATIENTS GENERAL CONDITION STABLE\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:  237     MG/DL\r\nFBS:    105 MG/DL\r\nBP:  130/80  MM HG\r\nCASE PLAN :\r\nDid not pass motion.\r\nSlept well\r\nC/S Report pending.\r\nSYP LOOZ HS.\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nS/B Dr Sooraj\r\n-----------------\r\nThanks for the referral\r\nDM x 40 years, not aknown hypertensive\r\non treatment with Dr Balan at Indira Gandhi Hospital - says that sugars have not been under control\r\nwas on a combination of oral antidiabetic medicines (Glucored forte and Gemer P2)\r\n\r\ninjury to the right lower limb 1 month back (alleged cockroach bite!)- not showed anybody despite requests from husband and son- developed worsening infection.\r\nSon says that RFTs were apprently done 1 year back - reports alright - not available to scrutinise now\r\n\r\ncurrently admitted with worsening of her infection since 09.08.2017. Renal dysfunction which was detected during admission has been steadily worsening since then. I&D was done on 10.08.2017 and she reports to having hematuria on the day of surgery. Unfortunately no intake output chart has been maintained though the ward sisters claim that she is putting out around 2.5 litres of urine. He urine has cleared up however microscopy shows trace albuminuria with active sediments.\r\n\r\nOther investigations show anemia with low MCV (she was transfused with i unit of blood) along with raised counts and worsening RFTs. She has also had hyponatremia which has been partially corrected. ECHO is WNL except thick LV. She has also been complaining of vomiting sensation and retrosternal heaviness which is not getting improved despite  PPIs.\r\n\r\nON examination she looks dry with pallor and the diabetic leg. There are no basal crepitations. her BPs over the past 2 days have been on the higher side - ? due to the renal involvement.\r\n\r\nImp: DM with Acute on CKD - to r/o underlying DN . The possibility of a Acute Glomerulonephritis also exists in view of the history of foot infection and active sediments\r\n?Peripheral vascular disease \r\n?Coronary artery disease though ECHO is wnl and since she has ECG changes I, aVL and lateral leads\r\n\r\nSuggest:\r\n1. Serum iron profile, USG abdomen, Doppler study of both lower limbs.Serum C3 and C4, ASO titre, repeat urine routine, 24 hrs urine protein, Serum Ca, Po4, uric acid \r\n2. Strict control of sugars\r\n3. To add Tab Alfalog 1-1-1\r\n4. To consider adding anti anginals\r\n5. Adequate hydration - 2.5 litres per day. To maintain a strict Intake output chart.  IV fluid if she is not taking adequate oral feeds.\r\n6. Inform reports. Daily RFTs, RRT sos.\r\n\r\nIssues discussed with patients son in detail. Possibilities explained. Guarded prognosis explained.\r\n\r\nShe requires regular nephrology reviews.\r\n\nSEen by DRA.K.Bhat.\r\nDRessings changed.The forefoot including big and 3 toes look unhealthy.Continue trt.\nSEEN BY DR.    TOM     &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nGRBS at 6am-101mg/dl informed to Dr.Manoj adviced Inj.Insugen R-4units s/c\r\nno  fresh complaints\r\ncontinue medications as per chart\r\nUSG to be done\r\niron profile to be done\r\nRepeat Sodium and stop Tab.Hyponat if sodium levels are normal\r\ncandid mouth paint to be given \r\nInj.Insugen R 4-4-4\r\nInj.Basalog 6 units.\r\nSeen by DRA.K.Bhat.\r\nContinue trt.Plan fro transmetatarsal amputation under SA on wednesday.\nGRBS at 6 pm 340mg/dl informed to Dr.Manoj and adv to give insugen R 12 units\nGRBS at 10pm-253mg/dl.Informed to Dr.Manoj adviced Inj.Basalog-10units s/c. \r\n\nGRBS at 6 am 125 mg/dl informed to Dr.Manoj and adv to give ins R 8 u\nSEEN BY DR.   TOM      &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nno fresh complaints\r\nrepeat urea,creat, TC\r\nemeset sos\r\nstop tab.hyponat\r\ninj.pansec to be made 1-0-1\r\ncontinue medications as per chart.\r\nSeen by DRA.K.BHat.\r\nDressings changed.The distal 2/3 of foot is unhealthy and necrosis at base of all toes on plantar and dorsal aspects,with pregangrene of toes.\r\nPlan for Rt Tarsometatarsal amputation under SA.16th Aug.\r\nPreop:Preoperative Instructions:\r\nGet informed written consent.\r\nNil oral as per Anesthetist advice.\r\nClean&dress foot.\r\nIV antibiotics.\r\nRpt Hb,FBS,Urea,CReat tomorrow.\r\nArrange 1 unit packed cells.\r\nMedical &Anesthetic fitness for the procedure.\r\nInform OT and anesthetist.\r\n=================\r\nInformed consent.\r\nThe little toe of right foot has previously been amputated. Now there is gangrene of tissues of remaining foot and toes there is large ulcer gangrenous infection and slough of right foot  and pus extending to rest of foot in deep layers.There is also decreased circulation.There is diabetes and neuropathy and nephropathy.This requires wound cleaning under Anesthesia.The dead tissues of the foot will be removed.Pus will be drained.The right foot will be assessed during operation,then amputation at proximal foot level will be done including all the remaining toes.The exact level will be decided during operation.Due to diabetes and decreased blood circulation ,wound healing will be delayed.During the recovery period strict nonweight bearing is needed to prevent wound failure.The overall recovery and function of the foot will need close observation.Further operations may be needed for infection and wound control and for wound healing.The above points have been explained and understood and full consent for operation and anesthesia is given.\r\n=====================\nGRBS at 6pm-143mg/dl.Informed to Dr.Lakshmi adviced Inj.Insugen R-4units s/c. \r\n\nGRBS at 10 pm 221mg/dl informed to Dr.Lakshmi and adv to give basalog 6 units\nSEEN BY DR.TOM         &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nno fresh complaints\r\npatient is NPO from 6 am \r\nGRBS at 6am-175mg/dl.Informed to Dr.Lakshmi. \r\nposted for surgery today\nGRBS at 6 pm 217mg/dl  informed to Dr.Lakshmi adv to give insugen R 6 units\r\nInj.Tramadol and Inj emeset to be given\nGRBS at 10 pm 285mg/dl informed to Dr.Lakshmi adv to give basalog 8 units\nSEEN BY DR.    TOM     &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nno fresh complaints\r\nGRBS-240mg/dl at 6 am informed to Dr.Lakshmi adv to give insugen R 10 U  \r\nInj.Insugen R 8-8-4\r\nInj.basalog 6 U\r\nRepeat counts day after tomorrow\r\nInj.Clexane 0.4 ml s/c restart\r\ncontinue medication as per chart\nGRBS at 6 pm  247mg/dl  informed to Dr.Manoj adv to give insugen R 8 units\nGRBS at 10 pm 248mg/dl  informed to Dr.Manoj adv to give basalog 10 units\nSEEN BY DR.   TOM      &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nno fresh complaints\r\n6am-GRBS-192mg/dl,informed to Dr.Manoj advised Inj.insugen r 12u s/c given. \r\nsyr.Potlor 10 ml 1-1-1 to be started\r\ninj.pactiv to be stopped\r\nTab.Acuvin sos\r\nCap.Pevesca Plus 0-0-1\r\nWH antibiotics and do as per Dr.Bhatts advice\r\nInsugen R :12-12-10unit\r\n Basalog:12unit. \r\nrepeat TC. electrolytes tom\r\ncontinue medications as per chart\r\nSeen by DrA.K.Bhat.\r\nContinue trt.Cap.Camyda 300mg 1-1-1.\nGRBS at 6 pm 112mg/dl informed to Dr.Tom and adv to give insugen R 8 units\r\nGRBS at 10 pm 122mg/dl informed to Dr.Tom adv to give basalog 6 u\n6AM-GRBS-129mg/dl,informed to Dr.Tom advised inj.insugen r 8u s/c given \r\nSeen by DrA.K.Bhat.\r\nDressings changed.Residual large wound needs observation.\r\n----------------------------------------------\r\n\r\nSEEN BY DR. Manoj and Dr Lakshmi\r\nPATIENTS GENERAL CONDITION STABLE\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:    122   MG/DL\r\nFBS:   129  MG/DL\r\n PPBS :    MG/DL\r\nBP:130/80    MM HG\r\nCASE PLAN :\r\nDressing changed, Discharge plan to be discuss with Dr Bhat\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nslept well.\r\nc/o lower abdominal pain in morning.\r\nwants to pass urine but unable to pass.\r\n\r\no/e mild tenderness on suprapubic region\r\np/a bladder  +.\r\n\r\nadv : urine catheter changed in aseptic condition. 1li. of clear urine drained.\r\nubdominal pain relived.\r\n\r\nINVE: URE AND TC\r\ninj.insugen R 14-14-12 s/c\r\ninj.basilog 14 s/c bedtime.\r\nSeen by DRA.K.BHat.\r\nContinue trt.\nSEEN BY DR. Lakshmi and Dr Manoj\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:       MG/DL\r\nFBS:     MG/DL\r\n PPBS :    MG/DL\r\nBP:    MM HG\r\nCASE PLAN :\r\nFeeling Better.\r\nTo do Periphral smear and TC\r\n\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\nSeen by DrA.K.Bhat.\r\nDressings changed.Slough of deep plantar mid foot region needs observation.Rpt C/S taken.Debrin,betadine dressing done.\nSEEN BY DR. TOM        &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:no specific complaints\r\nPAIN SCORE:1/5 \r\nFBS:149\r\nBP: 120/80   MM HG\r\nCASE PLAN :\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\nSeen by DR.A.K.BHAT.\r\nContinue trt.\r\n\nSEEN BY DR.Manoj and Dr Lakshmi\r\nPATIENTS GENERAL CONDITION STABLE\r\nBP: 130/70 mm hg\r\nCASE PLAN :\r\nInsugen R 14 -14-12\r\nBASALOG 16\r\nCulture report pending. \r\nContinue same.\r\nDressing today\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\nSeen by DRA.K.Bhat.\r\nDRessings changed.Stump raw area large and slough present-needs observation.Arterial Doppler rt leg.Plan fr D/C friday.\r\n\nSEEN BY DR.  TOM       &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:No specific complaints\r\nPAIN SCORE:1/5\r\nFBS: 151    MG/DL\r\nCASE PLAN :\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\nSeen by DRA.K.Bhat.\r\nContinue trt.\nSEEN BY DR.  Manoj\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:       MG/DL\r\nFBS:     MG/DL\r\n PPBS :    MG/DL\r\nBP:    MM HG\r\nCASE PLAN :\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\nSeen by DRA.K.Bhat.\r\nDRessings changed.Slough in deep plantar planes-needs observation.\r\nPlan fr D/C on monday.Tab.Cilostazole.Clopilet-Aspirin.Inj.Clindamycin 300mg 1-1-1.\nSeen by DRA.K.Bhat.\r\nContinue trt.\r\nSEEN BY DR.  Tom  &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nBLOOD SUGARS : \r\nPREDINNER:       MG/DL\r\nFBS:    136 MG/DL\r\nPPBS :    MG/DL\r\nBP:   130/90 MM HG\r\nCASE PLAN :\r\nPlan for d/c tomorrow.\r\nDoing well.\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nSEEN BY DR.   Manoj and Dr Lakshmi     \r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:       MG/DL\r\nFBS:     MG/DL\r\n PPBS :    MG/DL\r\nBP:    MM HG\r\nCASE PLAN :\r\n To do  TC, Serum. Iorn  and  Serum. Ferritin.\r\n Inj Ferenjitis  Stat\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\nSeen by DrA.K.Bhat.\r\nDRessings changed.\r\nAdvice:Change of dressing once in 2 days-betadine,debrin,jelonet.Oral Clinda 10 days.Cap.Yogut.NO WEIGHT BEARING ON OPERATED FOOT.REView OP Next week.\r\n'}, {'role': 'model', 'content': '\nIP Number: 7154\n\nPatient Number: 32044\n\nAdmission Date: 09-08-2017\n\nDischarge Date: 28-08-2017\n\nDiagnosis: gangrene fifth toe\r\ns/p tarsometatarsal amputation Rt foot\n\nClinical Exam(With BP): BP: 130/80mmhg\r\npulse : 70bpm\r\ntemp : afebrile\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: Chest X-Ray :\r\n\r\n\n\nXray findings: pallor - +\r\nRS- NVBS\r\nCVS- S1 S2 heard\r\nAbdomen- soft\r\nEXT- gangrene of the 5 th digit , abscess extending from the plnatar aspect of the 5 th digit to almost the mid foot and also the base of the 4 th digit\n\nDiscussion: 69 y old with H/o DM admitted with gangrene of the 5 th digit RT foot and also an abscess over the plantar aspect of the rt foot. Pt was admitted, started on I.V antibiotics, insulin basal bolus regimen for glycemic control and seen by surgeon, amputation of the 5th digit and slough debridement of the Rt foot was done on 10/8/17. There was worsening of renal function and was diagnosed with Post infectious Glomerulonephritis , which recovered slowly. The infectious process was still present and after discussing with the family, tarsometatarsal amputation was done. regular dressings were done and being discharged under stable condition and to do follow up dressings\n\nDiet: nan\n\nRemarks: advice to come for dressings alternate days\r\nadvice to take the In ferinject 500mg in 100ml NS over 15 min the next visit'}]"
7312,"[{'role': 'user', 'content': '\nIP Number: 7312\n\nPatient Number: 7809\n\nPatient Name: P K JYOTHIPRAKASH\n\nGender: M\n\nDate of Birth: 15-09-1945\n\nAddress: VELIMPARAMBIL HOUSE, AYYAMPILLYCHIRA LAN\n\nPincode: 682306.0\n\nPhNo: nan\n\nAdmission Date: 30-09-2017\n\nDischarge Date: 16-10-2017\n\nDiagnosis determined by the doctor when the patient was admitted: DIABETIC FOOT\nTYPE 2 DIABETES MELLITUS\nMixed hyperlipidaemia\nEssential (primary) hypertension\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: Pt came with c/o swelling at base of R big toe since 4 days.H/o few fever spikes since 3 days.\n\nXray information: nan\n\nClinical examination: Swelling at base of R big toe -discharge +,bleeding +\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: BETTER NIL C/O\nCulture report awaited\r\n\nSEEN BY DR. LEKSHMI        &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:T2DM\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nFBS: 128    MG/DL\r\nBP: 140/80   MM HG\r\nCASE PLAN : TO DO TC TMRW\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nSEEN BY DR. TOM        &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:No specific complaints\r\nFBS:  114  MG/DL\r\nCASE PLAN :To continue same trt\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nSSEN BY DR TOM BABU & TEAM . BP: 130/80 MM HG. GRBS:112 MG/ DL.\r\nCASE PLAN :INJ . MONOSCOT STOP. \r\nINS. REGULAR 20-20-20. \r\nBASALOG 16 U @ BED TIME . CST\nSeen by DRA.K.BHat.\r\nRt big toe infective gangrene with pus,necrosis ball of big toe.Plan:Big toe amputation and slough excision under SA.Continue trt.\r\n\nSeen by DRA.K.Bhat.\r\nC&d done.Plan fr big toe amputation under SA on tuesday.Preop. tests.Medical fitness,.\nSEEN BY DR.  Lakshmi       &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:No specific complaints\r\nFBS:129     MG/DL\r\nCASE PLAN :\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nSEEN BY DR . TOM BABU & TEAM .\r\nBP: 140/90 MMHG \r\nFBS : 122 MG /DL \r\nCASE PLAN : INS . REGULAR 22-22-20 U . BASALOG 16U\r\nCONTINIUE SAME TREATMENT.\r\nSeen by DRA.K.BHat.\r\nDRessings changed.\r\nPosted for right left big toe amputation &slough excision under Epidural 10th oct. 7.30 am.\r\nPreoperative Instructions:\r\nGet informed consent.\r\nNil oral as per Anesthetist advice.\r\nClean&dress area on morning of operation.\r\nIV antibiotics.\r\nMedical &Anesthetic fitness for the procedure.\r\nInform OT and anesthetist.\r\n===============\r\nInformed consent-\r\nThere is severe infection of right big toe including bone and other tissues with pus collection,extending upward.There is diabetes and neuropathy.This needs bone nibbling and shortening of the toe,to control the infection.During operation all the infected unhealthy bone and skin andsoft tissues will be removed.The amount and length of shortening(amputation) of the toe will depend on the findings during operation. Due to neuropathy&diabetes the control of infection and wound healing needs close observation.Wound healing may be delayed.The importance of offloading and long term footcare and footwear has been explained.Having understood the above,consent for operation under anesthesia is given.\r\n===============\nC/S/B Dr.Sandeep \r\nc/o -Urinary retention\r\n       Pt removed Foleys by himself\r\nDRE-Grade 2 smooth\r\n\r\nAdv: T.SILOFAST-D 8mg HS\r\n        T.chymoral fore 1 TID\r\n        Catheter removal after 5 days\r\n        Shall review then\r\n\r\n\nSEEN BY DR.   TOM      &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:No specific complaints\r\nFBS:104     MG/DL\r\nCASE PLAN :\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\nSeen by DRA.K.Bhat.\r\nContinue trt.\nSEEN BY DR.   TOM      &TEAM\r\nPATIENTS GENERAL CONDITION STABLE, on foleys catheter\r\noutput good\r\nC/O:No specific complaints\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:       MG/DL\r\nFBS:  113   MG/DL\r\n PPBS :    MG/DL\r\nBP:    MM HG\r\nCASE PLAN :podiatry consultation\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\nSeen by DRAK.Bhat.\r\nDressings changed,Clean.\r\nContinue trt.\nSeen by A.K.Bhat.\r\nContinue trt.Tab.Oxcip 500mg 1-0-1.\nSEEN BY DR. Tom        &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:No specific complaints\r\nFBS: 238    MG/DL\r\nCASE PLAN :Change to oral antibiotics\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nSeen by DR.A.K.Bhat.\r\nContinue trt.?Plan fr D/C tmrw.\nSeen by DRA.K.Bhat.\r\nDRessings changed.Clean.\r\nAdv:Change of dressing once in 2 days-betadine,cuticell.NO weight bearing on operated area foot.Oral ABx 2 weeks.,.REview OP 1 week.,23rd OCt.\r\n'}, {'role': 'model', 'content': '\nIP Number: 7312\n\nPatient Number: 7809\n\nAdmission Date: 30-09-2017\n\nDischarge Date: 16-10-2017\n\nDiagnosis: Infected Swelling R big Toe\r\nHallux valgus Lt with infected Bunion on the left big toe\r\ns/p multiple I&D done under LA\r\ns/p amputation of the big toe RT (10/10 17)\n\nClinical Exam(With BP): nan\n\nSystolic BP: 172.0\n\nDiastolic BP: 77.0\n\nPhysical examination: Chest X-Ray :Normal\r\n\r\n\n\nXray findings: Swelling at base of R big toe -discharge +,bleeding +\n\nDiscussion: 72 yr old with H/O DM admitted with acute swelling RT big toe x 4days. He was admitted, started on basal bolus regimen and I.Vantibiotics.  Pt was seen by Podaitry surgeon, I & D of the abscess and  regular dressings were done. Despite best efforts the toe was unviable and hence amputation of the big toe was done on 10/10/17. post op , urinary foley catheterisation was done because of urinary retention. Pt had a trauma in the post op where he pulled the foley catheter and was seen by urology . and under supervision - another  foley catheter was placed which was kept for 5 days. Regular dressings were done post op and the wound is healing well with treatment. Foleys catheter was removed after 5 days.Pt discharged on a stable condition\n\nDiet: nan\n\nRemarks: If You experience  palpitations, nervousness, sweating, shivering, shakiness, blurred vision, confusion, unconsciousness.\r\nImmediately eat/drink something that contain direct sugar (glucose tab, ½ glass juice, candies) if symptom continue, call your Doctor.\r\nAlternate dressing at our podiatry as adviced\r\nSMBG as adviced - To maintain a log book\r\nReview at Endo & Podiatry OP after 1 week with PC'}]"
7520,"[{'role': 'user', 'content': '\nIP Number: 7520\n\nPatient Number: 40459\n\nPatient Name: MEENAKSHI KARUNAKARAN (IN)\n\nGender: F\n\nDate of Birth: 05-12-1948\n\nAddress: 8 B.PAUL ABROA RESIDENCY\n\nPincode: nan\n\nPhNo: nan\n\nAdmission Date: 05-12-2017\n\nDischarge Date: 21-12-2017\n\nDiagnosis determined by the doctor when the patient was admitted: Essential (primary) hypertension\nTYPE 2 DIABETES MELLITUS\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: nan\n\nXray information: 17/11/17- diffuse atheromatous changes with calcified plaques in distal aorta,B/L iliac and lower limb arteries\r\n24/11/17 PUS C AND S-No growth\r\n\n\nClinical examination: nan\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: Seen by DRA.K.BHat.\r\nLeft foot-Large ulcer over amputated 3rd,4th,5th toes.REsidual slough plantar aspect flap.Skin gangrene lateral aspect 2nd toe.Distal pulsations not felt.\r\nAdv:Daily Betadine,debrin dressings.Crepe bandage.IV ABx continue.WH Clopivas A.\nSEEN BY DR. TOM        &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:No specific complaints\r\n\r\n FBS : 98   MG/DL\r\nBP: 150/80   MM HG\r\nCASE PLAN :\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nSEEN BY DR.  TOM BABU       &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nBLOOD SUGARS : \r\nFBS: 202    MG/DL\r\nBP:130/80    MM HG\r\nCASE PLAN :T. ALLEGRA STAT , STEAM INHALATION . CST\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nSEEN BY DR. TOM BABU        &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nBLOOD SUGARS : \r\nFBS: 127    MG/DL\r\nBP:120/70   MM HG\r\nCASE PLAN :DR. BHAT REVIEW TODAY . CARDIAC CONSULTATION .\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\nSeen by DRA.K.BHat.\r\n\r\n\nPosted for left mid foot amputation under epidural,12th dec 4.30 pm.\r\nPreoperative Instructions:\r\nGet informed consent.\r\nNil oral as per Anesthetist advice.\r\nClean&dress area on morning of operation.\r\nIV antibioticscontinue.\r\nMedical &Anesthetic fitness for the procedure.\r\nInform OT and anesthetist.\r\n--------------------------------\r\nInformed consent.\r\nThe 5th,4th&3rd toes has previously been amputated. Now there is pregangrene of 2nd toe and there is large ulcer of amputated area&gangrenous infection and slough of left foot  and pus extending to rest of foot regions in deep layers also.There is also decreased circulation.There is diabetes and neuropathy.This requires wound cleaning under Anesthesia.The dead&infected tissues of the foot will be removed.Pus will be drained.The left foot will be assessed during operation,then amputation at healthy,viable (probably mid foot level) will be done.The exact level will be decided during operation.Due to diabetes and decreased blood circulation ,wound healing will be delayed.Sometimes repeat operation may be needed.During the recovery period strict nonweight bearing is needed to prevent wound failure.The overall recovery and function of the foot will need close observation.The above points have been explained and understood and full consent for operation and anesthesia is given.\r\n-------------------------------------\nSEEN BY DR. TOM BABU        &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nBLOOD SUGARS \r\nFBS: 137    MG/DL\r\nBP:140/90    MM HG\r\nCASE PLAN :RESTART T. CLOPILET . NUTRTITION REVIEW TODAY . \r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nSEEN BY DR.  TOM BABU       &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nBLOOD SUGARS :\r\nFBS:185     MG/DL.\r\nBP: 140/80   MM HG\r\nCASE PLAN :CATHETER TO BE REMOVE TODAY. DREESING TOMAROW. CST\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nBetter , afebrile.\r\nSeen by DRA.K.BHat.\r\nDRessings changed.Clean.\nSeen by DRA.K.Bhat.\r\nContinue trt.Cap.Camyda.\nBetter, afebrile.\nSEEN BY DR. LAKSHMI        &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nBLOOD SUGARS :\r\nFBS: 129    MG/DL\r\nBP: 150/80   MM HG\r\nCASE PLAN :PLAN FOR DISCHARGE AFTER DR BHAT REVIEW. \r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\n\r\n\nSeen by DRA.K.Bhat.\r\nDRessings changed.Clean.\r\n\nSEEN BY DR. TOM BABU        &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nBLOOD SUGARS :\r\nFBS: 136    MG/DL\r\nBP:140/80    MM HG\r\nCASE PLAN : DR BHAT REVIEW TODAY . CST\r\nPATIENT CONDITION ( AS EXPLAINED TO THE BYSTANDERS)\r\nSeen by DRA.K.Bhat.\r\nPlan fr D/C tmrw.\r\n\nBetter , D/d today.\r\nSeen by DRA.K.Bhat.\r\nDRessings changed.Clean.\r\nAdv:Change of dressings once in 2 days-betadine,cuticell.Oral AB x 2 weeks.Review OP Tuesday 26th dec.'}, {'role': 'model', 'content': '\nIP Number: 7520\n\nPatient Number: 40459\n\nAdmission Date: 05-12-2017\n\nDischarge Date: 21-12-2017\n\nDiagnosis: CVA\r\nS/P tarsometarsal amputation on 12/12/17\r\nCAD\n\nClinical Exam(With BP): nan\n\nSystolic BP: 140.0\n\nDiastolic BP: 80.0\n\nPhysical examination: 17/11/17- diffuse atheromatous changes with calcified plaques in distal aorta,B/L iliac and lower limb arteries\r\n24/11/17 PUS C AND S-No growth\r\n\n\nXray findings: nan\n\nDiscussion: 69 yr old with H/o DM, CAD, POVD admitted with discolouration of 2nd toe on the left side x 1 day. Pt had an amputation left 3rd,4th,5th toes on 18/11/17.Peripheral drug elluting balloon angioplasty done on 23/11/17. Pt was admitted, started on I.V antibiotics, Insulin basal bolus regimen for glycemic control. seen by surgeon, after continuing on the antibiotics for few days, was decided to have a tarsometarsal amputation. Mid foot amputation was done on 12/12/17. post op was uneventful. pt being discharged under stable condition\r\n\n\nDiet: nan\n\nRemarks: nan'}]"
8603,"[{'role': 'user', 'content': '\nIP Number: 8603\n\nPatient Number: 12\n\nPatient Name: P.J.JOHN\n\nGender: M\n\nDate of Birth: 18-02-1935\n\nAddress: 32-NEPTUNE COUNTRY\n\nPincode: 682020.0\n\nPhNo: 9388143550\n\nAdmission Date: 26-12-2018\n\nDischarge Date: 10-01-2019\n\nDiagnosis determined by the doctor when the patient was admitted: nan\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: nan\n\nXray information: nan\n\nClinical examination: nan\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: SEEN BY DR.   Karthik      &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:   225    MG/DL\r\nFBS:   232  MG/DL\r\nBP:    MM HG\r\nCASE PLAN : Chest x-ray, PSA\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nSEEN BY DR.  Manoj       &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:    314   MG/DL\r\nFBS:  177   MG/DL\r\nBP:    MM HG\r\nCASE PLAN :\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\ns/b Dr Sureshkumar (neurologist)\r\n\r\nURTI better but still has throat pain\r\n\r\nSensorium better\r\n\r\nGCS 15/15\r\n\r\nVITALS STABLE\r\nplan\r\n\r\nContinue antibiotics \r\nBetadine throat gargle \r\nTb DOLO 650 sos.\nSEEN BY DR.  Tom       &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O: No specific complaint\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:   205    MG/DL\r\nFBS:  125   MG/DL\r\nBP:    MM HG\r\nCASE PLAN : Continue same, Betadine gargle\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\ncalled to attend to patient  for dysphagia and ?pain in the throat o/e pt uncooperative disoriented, afebrile neck normal nose normal ears impacted wax throat no {obvious} lesions seen ?dysphagia due toneuromuscular cause. suggest neurological opinion continue same medication. soliwax ear drops for both ears three drops three times daily after food for one week\nSEEN BY DR.  Tom  &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O: WHEEZING PRESENT\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:122MG/DL\r\nFBS:125MG/DL\r\nBP:  120/70  MM HG\r\nCASE PLAN :Tab.Allegra 120 0-0-1\r\n Continue same, Betadine gargle\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\nSEEN BY DR.  Lakshmi       &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:    135   MG/DL\r\nFBS: 144    MG/DL\r\nBP:    MM HG\r\nCASE PLAN :\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nSEEN BY DR. LAKSHMI &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:FEVER\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:236MG/DL\r\nFBS:141MG/DL\r\nBP:130/80MM HG\r\nCASE PLAN :\r\nInj.Clexane 0.4mg 1-0-0\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nSEEN BY DR.   Tom      &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O: No specific complaint\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:    159   MG/DL\r\nFBS: 136    MG/DL\r\nBP: 110/70   MM HG\r\nCASE PLAN : Chest physio\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nSEEN BY DR. Tom &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:no fresh complaints,93% without O2\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:200 MG/DL\r\nFBS:155 MG/DL\r\nBP:  160/90  MM HG\r\nCASE PLAN :continue same treatment \r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nSEEN BY DR.         &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O: No specific complaints\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:    194   MG/DL\r\nFBS:  189   MG/DL\r\nBP: 150/80   MM HG\r\nCASE PLAN : Continue same\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nSEEN BY DR. Karthik  &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:NO specific complaint,better\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:210MG/DL\r\nFBS:173 MG/DL\r\nBP: 140/90 MM HG\r\nCASE PLAN : \r\ncontinue same treatmen\r\nmobilze\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS.\r\n\nSEEN BY DR.  Tom       &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O:mood swings \r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:    223   MG/DL\r\nFBS:   158  MG/DL\r\nBP:  150/90  MM HG\r\nCASE PLAN :\r\nstart oral feed if tolerating remove RT \r\nDr suresh sir consultation \r\nphysio \r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nSEEN BY DR.   Lakshmi      &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O: No specific complaint\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER:  264     MG/DL\r\nFBS:   166  MG/DL\r\nBP: 150/90   MM HG\r\nCASE PLAN : Continue same\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nSEEN BY DR.TOM   &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O: No specific complaint\r\nPAIN SCORE:\r\nBLOOD SUGARS : \r\nPREDINNER: MG/DL\r\nFBS: 163MG/DL\r\nBP: 140/80   MM HG\r\nCASE PLAN : Continue same,plan for discharge tmw\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS'}, {'role': 'model', 'content': '\nIP Number: 8603\n\nPatient Number: 12\n\nAdmission Date: 26-12-2018\n\nDischarge Date: 10-01-2019\n\nDiagnosis: Lower respiratory tract infection\r\nEncephalopathy - secondary to infection\r\nMild Hyponatremia\r\nCAD - s/p CABG\n\nClinical Exam(With BP): nan\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: Chest X-Ray: No significant changes.\r\nUSG Abdomen - Mild fatty liver \r\nEcho - Mild concentric LVH,dilated LA., Good LV systolic function Stage 1 diastolic dysfunction.\n\nXray findings: Conscious, less responsive, intermittent alteration in sensorium -not consistently obeying commands\r\nVitals stable\r\nChest : Rhonchi with crepitations\r\nCVS - S1 S2 +\n\nDiscussion: Mr.P J John, 83 year old gentleman who is a k/c/o DM, HTN, CAD (p/s CABG) and Prostate Ca, admitted with difficulty in walking, stiffness both hands and legs since 3 days. H/o cough was present since 3-4 days prior to admission here. Routine investigations were sent, started on with IV antibiotics, IV fluids and basal bolus insulin regimen. During the course of hospital he had two episodes of hyponatremia and managed conservatively. Pulmnology consultation was taken for cough and intermittent breathlessness and 2 liters of Oxygen support was given. In view of his drowiness & altered sensorium, Ryles tube was inserted and feeding was started. His sugar level were well controlled while in the hospital. Neurology consultation done and an impression of  possible encephalopathy was made and adviced for CT-brain,which was normal. ENT and Cardiology consultation was sought. Echo done showed mild LVH with good LV systolic function. He  clinically improved with treatment, Ryles tube removed and started oral intake. He is discharged in stable condition.\n\nDiet: nan\n\nRemarks: Review SOS if develop joint stiffness,altered sensorium or refuse food intake.\r\nIf You experience  palpitations, nervousness, sweating, shivering, shakiness, blurred vision, confusion, unconsciousness.\r\nImmediately eat/drink something that contain direct sugar (glucose tab, ½ glass juice, candies) if symptom continue, call your Doctor.\r\nReview after 2 week in Endo/Neurology OP with PPBS'}]"
9663,"[{'role': 'user', 'content': '\nIP Number: 9663\n\nPatient Number: 321\n\nPatient Name: M.V JAYAPRAKASAN\n\nGender: M\n\nDate of Birth: 24-05-1954\n\nAddress: MANNARPARAMBIL,RAMANEEYAM\n\nPincode: 682024.0\n\nPhNo: 9447319554\n\nAdmission Date: 14-02-2020\n\nDischarge Date: 01-03-2020\n\nDiagnosis determined by the doctor when the patient was admitted: nan\n\nData from scanning: nan\n\nImpression data from scanning: nan\n\nDiscussion: nan\n\nXray information: nan\n\nClinical examination: Concious oriented\r\nCvs-s1s2+\r\nRs-b/l chest clear\r\nP/a-mildly distended\r\nFoleys and RT insitu\n\nPrecautions to be taken while treating the patient: nan\n\nRemarks: SEEN BY DR.  Manoj       &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O: No specific complaint\r\nBLOOD SUGARS : \r\nPREDINNER: 122      MG/DL\r\nFBS: 186    MG/DL\r\nBP: 143/80   MM HG\r\nCASE PLAN : Urology consultation. Continue same\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nSEEN BY DR. Tom        &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O: vomiting 1 episoide today morning,gen tiredness.\r\nPAIN SCORE: 1/10\r\nBLOOD SUGARS : \r\nPREDINNER:       MG/DL\r\nFBS:     MG/DL\r\nBP: 140/80   MM HG\r\nCASE PLAN : Gastro consultation today.\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nSEEN BY DR.    Lakshmi     &TEAM\r\nPATIENTS GENERAL CONDITION STABLE\r\nC/O: mild nausea\r\nPAIN SCORE:0/10\r\nBLOOD SUGARS : \r\nPREDINNER:   242    MG/DL\r\nFBS:  111   MG/DL\r\nBP:   124/70 MM HG\r\nCASE PLAN : Oral feed to be started today.\r\nPATIENT CONDITION  EXPLAINED TO THE BYSTANDERS\r\n\r\n\nsend RFT,Sr.Electrolytes tomorrow\r\nEnema to be given\r\nAs advised by Dr.Tom.\nT.Nexito 5mg 1-0-0 as advised by Dr.Suresh\ncase reviewed by dr shelley \r\ncva pt hypothyroid and t2dm on trrx and and insulin \r\n on ppi and ganatone \r\nc/o constipation and abd bloating gas occ vomiting \r\n features are c/w gastroparesis \r\n o/e abd soft no organomegaly \r\n adv\r\n s na/ k,\r\ntab acotiomide 100mg tds \r\nd peg plus 3tsp in one glass of water at bed time \r\nemeset 4 mg tds \r\nstop sucrafil \r\n continue ppi tab \r\n stop ppi inj\r\ngive asprin after food \r\ntab gerbiza 2 hs today only\r\ncorrect electrolytes sos\r\nincrease total fluid intake to 2000 + ml perday\r\nshall review sos \r\n'}, {'role': 'model', 'content': ""\nIP Number: 9663\n\nPatient Number: 321\n\nAdmission Date: 14-02-2020\n\nDischarge Date: 01-03-2020\n\nDiagnosis: H/o CVA with Left sided Hemiplegia\r\nIMP - Post Stroke Dysphagia,\r\n?Gasteroparesis.\n\nClinical Exam(With BP): He presented with c/o vomiting (multiple episodes) since one day and high glycemia . Had been admitted for UTI at Renai one week back.He is a k/c/o Type 2 DM, COPD, CVA on treatment.\n\nSystolic BP: 0.0\n\nDiastolic BP: 0.0\n\nPhysical examination: Chest X-Ray :\r\n\r\n\n\nXray findings: Concious oriented alert\r\nCVS -s1s2+\r\nRS- b/l chest clear\r\nP/A-mildly distended\r\nFoleys and RT insitu\r\nLocal Examination   :N/E GR 0-1/5 POWER BOTH ul/ll,\r\nb/l palatal movement normal\r\ngag ++\r\n\n\nDiscussion: Mr.Jayaprakash 65 years old male who is a k/c/o Type 2 DM, HTN, CVA,COPD admitted  with multiple episodes of  vomiting , abdominal discomfort and high glycemia  .On admission his blood sugars were over 400mg/dl ,was on large doses of insulin- (200 units per day).Labs sent were normal .  He was started on   PPIs, Iv fluids and other supportives.He was on RT feed and Foleys catheter. His intake/output chart was monitored .Neurology and Gasteroenterology consultation were taken .Impression  of Post stroke dysphagia and ?gasteroparesis was made  .During the hospital stay his feed was changed from RT to Oral gradually with semi solid food .But he couldn't tolerate well, his symptoms persisted despite of our best efforts. His glycemia was very well  controlled with basal bolus insulin regimen(on minimal dose) . He is referred to higher centre, for further management and evaluation.\n\nDiet: nan\n\nRemarks: Review in Medicine OPD---------.\r\nIf You experience  palpitations, nervousness, sweating, shivering, shakiness, blurred vision, confusion, unconsciousness.\r\nImmediately eat/drink something that contain direct sugar (glucose tab, ½ glass juice, candies) if symptom continue, call your Doctor.\r\n\r\n""}]"