Chakravarty Swapna

60 Y  old  Female, DOB: 06/10/1961

Account Number: 478605
C 333 ANEW ASHOK, C 333 A,NEW ASHOK, Gautam Buddha
Nagar, UP - 201301
Home: 9958184185   
Guarantor: Chakravarty Swapna   
Insurance: HCLT Dependent
Appointment Facility: HCL Healthcare Noida 24 Center

10/06/2022 Dr Pallavi Prasad

Reason for Appointment

1. VC Consult for EHC
2. Burning sensation in vagina, off and on
3. Leakage of urine while coughing, sneezing,

Assessments/ Health Conditions Identified

1. Encounter for routine gynecological examination - Z01.41 (Primary)
2. Stress incontinence (female) (male) - N39.3

Treatment
 
1. Encounter for routine gynecological examination 

Clinical Notes: Pap's test report, NILM, discussed with the patient.  

2. Stress incontinence (female) (male) 

Notes: KIEGEL'S EXERCISES AS ADVISED FOR 3 TO 6 MONTHS.  

3. Others  

Notes: EVALON CREAM LOCALLY TWICE DAILY FOR 10 DAYS, OINTMENT SURFAZ SN, LOCALLY 3 TIMES DAILY FOR 7
DAYS.  

Wellness Plan
Drink plenty of liquids and take balanced, nutritious diet
In case of any medical urgency/emergency, do not delay in seeking medical advice and reaching out to the HCL Healthcare?s
Medical Helpline (Phone Number: 92110-22223) or other nearby doctor/hospital promptly. Some COVID-19 related danger signs
include: (a) Breathlessness, (b) Oxygen saturation level less than 94%, (c) Drowsiness / Low alertness, (d) Distressing cough, (e)
Decreased urine output or dark-coloured urine, and (f) Weakness in any body part.

Next Suggested Appointment

as required

History of Present Illness

Phase 3 Health Index: 

       Burning sensation in vagina, off and on, since 1 to 2 years.Leakage of urine while coughing, sneezing, , CONSENT: Before
initiation of the present consult, the patient/consultee was informed and explained about telemedicine, that is, the facility of
virtual consult/tele-consult through a tele-health mode, including its limitations, the rights and duties of the provider and the
patient/consultee as per the statutory guideline for the same, and also the fact that the present consult?s audio/video call may be
recorded and used by other clinical providers confidentially for internal training and quality purposes. After having understood
it, the patient/consultee has given his/her informed, verbal consent for this virtual consult.
       Patient has no specific complaints
       not a k/c/o DM/SHT/BA.

Allergies
CILACAR: SWELLING OVER LEGS

Past Medical History

     Hypothyroidism.
     Hypertension.

Surgical History
tubal ligation
Hospitalization/Major Diagnostic Procedure
admitted for above

Gyn History
Date of Last Period Menopausal. 

Last PAP Smear Never. 

Menopause:
     
 Began at age: 53

OB History
GPAL: 
P2L2 A0, LCB 36 YEARS. 

Total pregnancies 
2. 

Total living children 

2. 

NVD 
2. 

Family History
Mother: diagnosed with Unspecified essential hypertension
Father: diagnosed with Unspecified essential hypertension
Siblings: diagnosed with Unspecified essential hypertension, Diabetes mellitus without mention of complication, type II or
unspecified type, not stated as uncontrolled, Unspecified heart disease, Hypothyroidism, unspecified

Social History
Social History: 

      Physical Activity 

         Do you participate in at least 150 minutes of moderate-intensity aerobic activity at least 75 minutes of vigorous-intensity
aerobic activity, or an equivalent combination weekly?
 Yes

      Sleep 

         Do you sleep for at least 6 hours daily on an average?

 Yes

      Smoking - 

         Do you smoke?

 No

      Tobacco - 

         Do you chew tobacco?

 No

      Alcohol - 

         Do you consume alcohol?

 No

      Stress 

         Over the last 2 weeks have you been bothered by the feeling of nervousness, anxiety, being on edge, or not being able to stop
or control worrying?
 No

Vital Signs
Wt-kg 93.0 kg, Ht-cm 151.9 cm, BMI 40.31 index, Blood Pressure 140/80 mm Hg, Temp 96.5 F, RBS n/a, HR 78 /min, Oxygen
sat 98 %, Pain scale 0 (0-10), Wt 205.03, Ht 59.8.

Examination
General Examination:
      
examination could not be done due to virtual mode of consult through audio call.

Electronically signed by Dr Pallavi Prasad on 10/06/2022 at 10:54 AM IST

Sign off status: Pending

HCL Healthcare Noida 24 Center

 A-5 Sector 24
Noida UP 201301
Tel: 1204124250
Fax: 

HCL Avitas Pvt. Ltd.

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

Patient: Chakravarty Swapna    DOB: 06/10/1961    
Progress Note: Dr Pallavi Prasad    10/06/2022
Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)