OPD - INITIAL ASSESSMENT FORM

Thu 11.Apr.2024 12:44

Patient's Name : SAKSHAM SETU
Address : MUMBAI MAHARASHTRA
MR.No. : UHID : MR240008541 Evolko ID : 3381027
Age / Sex : 21Y / M Mobile : +916203944086

Clinical Notes :
Chief Complaint: C/o EPISODIC DIZZINESS SINCE 16 MARCH - SHORT EPISODES
NAUSEA
OCT AND FEB
NO HEADACHES

Details:
Department: Neuro consultation

Drug Allergy: No Known Allergies

Current Medication: - None

Vitals

Examination : EOM NORMAL

DIX HALL PICK NORMAL
MRI NORMAL
Serum B12- 193
Vitamin D level - 10.90

Diagnosis: Meniere's Disease, EPISODIC DIZZINESS - LEFT SNHL

DOSAGE (GENERIC DRUG) BRAND NAME DOSAGE ROUTE FREQUENCY DURATION

FORM
TAB (STRUGERON 25 MG) 1 Tab Orally sos for 5 Days
TAB (PANTOCID 40 MG) 1 Tab (Before Orally once a day for 10 Days
Breakfast)
INJ OPTINEURON 3ML 3 ML IM weekly for 5 Weeks
OPTINEURON 3ML
FOLLOWED BY: 3 ML IM monthly for 5 Months
OPTINEURON 3ML
CAP CHOLECALCIFEROL 60000 IU 1 Tab Orally weekly for 3 Months
UPRISE D3 60K
TAB BENFOTIAMINE + METHYLCOBALAMIN 1 Tab Orally once a day for 3 Months
+ ALPHA LIPIOC ACID + CHROMIUM +
INOSITOL + FOLIC ACID + PYRIDOXINE +
NUHENZ

Instructions: LIFE STYLE MODIFICATIONS

Time to time food
Sleep 6 -8 hours.

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 OPD - INITIAL ASSESSMENT FORM
Thu 11.Apr.2024 12:44
Patient's Name : SAKSHAM SETU
Address : MUMBAI MAHARASHTRA
MR.No. : UHID : MR240008541 Evolko ID : 3381027
Age / Sex : 21Y / M Mobile : +916203944086

Yoga Meditations
Walking 30min per day.

Next Follow Up: After 30 DAYS.

Consultant's Name : Dr. Nilesh Chaudhary, MBBS,

DNB (Gen. Medicine), DNB (Neurology)
Regd. NO. 2005124220

Date : Thu 11.Apr.2024 Time : 12:44 Consultant's Signature : Stamp :

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