Patient intake review

Abnormal investigation values (3)

Fasting Blood Sugar: 186 mg/dL (normal 70–110)HbA1c: 8.9 % (normal < 5.7)Serum Creatinine: 1.4 mg/dL (normal 0.6–1.2)

Standard clinical history (Allopathy)

Chief Complaint

Chief complaint: Chest pain or heaviness

History of Present Illness

Onset & duration: Started today
Severity: Severe
Alarm features: Pain going to the left arm or jaw, Cold sweating

Past History

Past medical & surgical history: Sugar (Diabetes), Blood pressure

Medication & Allergy

Drug history: Yes, every day
Allergy history: No, never

Family History

Family history: Heart problem, Sugar

Personal History

Personal history: Beedi or cigarette

Review of Systems

Review of systems: Weight loss, Passing urine often

Prior Investigations

Prior investigations: Yes, blood test

Documents digitised this visit

Prescription2026-06-18

Out-patient Prescription

District General Hospital, Cardiology OPD

Diagnosis found

Type 2 Diabetes MellitusEssential Hypertension

Medicines

Metformin

500 mg · Twice daily · 3 months

Telmisartan

40 mg · Once daily (morning) · 3 months

Atorvastatin

10 mg · Once at night · 3 months

Doctor's note

Advised salt restriction and daily 30 minute walk.

Laboratory report2026-08-02

Laboratory Report — Biochemistry

Civil Hospital Central Lab

3 values are outside the normal range. The doctor has been informed.

Diagnosis found

Poor glycaemic control

Test values

Fasting Blood Sugar

186 mg/dLNormal: 70–110

HbA1c

8.9 %Normal: < 5.7

Serum Creatinine

1.4 mg/dLNormal: 0.6–1.2

Haemoglobin

12.8 g/dLNormal: 12–16

Total Cholesterol

196 mg/dLNormal: < 200

Discharge paper2025-11-27

Discharge Summary — Medicine Ward

District General Hospital, Ward 4

Diagnosis found

Community acquired pneumoniaType 2 Diabetes Mellitus

Medicines

Amoxicillin-Clavulanate

625 mg · Thrice daily · 7 days

Insulin (Human Mixtard)

12 U · Before breakfast · On discharge

Doctor's note

Admitted for 5 days with fever and cough. Improved on antibiotics. Review after 1 week.