MK

{{ patientName }} 34 yrs · Female

            UHID PAT-100482|
            O+ve|
            +91 98xxx xx432
          

ALLERGIES

Penicillin (severe), Sulfonamides (mod)

CHRONIC Hypothyroidism Menorrhagia

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Token A-024 · OPD-2

Dr. Anita Rao · Gen. Medicine

Follow-up visit In Consultation

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Patient Snapshot

BMI

22.1

Normal range

LAST VISIT

Yesterday

15 Jun 2026

VISITS (1Y)

5

LMP

8 days ago

heavy flow

Active Problems 3

Hypothyroidism

E03.9 · since Jan 2024

Menorrhagia

N92.0 · recurrent

Iron deficiency anaemia NEW

D50.9 · this visit

Carried forward

Continuing items from earlier visits

ONGOING MEDICATION

Thyroxine 25mcg · 1-0-0

since Jan 2024 · do not stop

PENDING FROM LAST VISIT

CBC + 24h urine

Results now available · review today

1

Chief Complaints

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FREQUENT IN THIS CLINIC

2

Vitals & Examination

Recorded today 11:08 · Nurse S.

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Examination notes

Pallor of conjunctiva and nail beds. Koilonychia of fingernails. No icterus, no pedal edema. CVS: S1S2 normal, soft systolic flow murmur. Chest clear.

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Diagnosis

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SUGGESTED FROM HISTORY & LABS

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Prescription

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2 safety checks — review before signing

· Allergy: patient is allergic to Penicillin — current Rx is clear.
· Interaction (moderate): Tranexamic acid raises thrombotic risk; avoid with combined oral contraceptives.

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Investigations

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FREQUENTLY ORDERED

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Advice & Follow-up

Patient instructions

Take iron with vitamin-C source; avoid tea/coffee within 1 hour of the dose. Iron-rich diet (leafy greens, jaggery, dates). Return earlier if breathlessness, chest pain or palpitations worsen.

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Follow-up

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DATE

INSTRUCTION FOR VISIT

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Referral

Clinical Alerts 2

Critical: Haemoglobin 8.9 g/dL

Below transfusion-review threshold trend. Started oral iron.

TSH 5.8 mIU/L — mildly high

Consider thyroxine dose review.

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View note Report

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Checked against today’s prescription — no interactions found.

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Records & Lab Orders

All investigations · this follow-up & previous visits

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Showing all investigations · newest first

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Only one recorded result — no values from earlier visits to trend yet.

SEVERITY Mild Moderate Critical

FINDINGS

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IMPRESSION

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ROUTE

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REASON / DIAGNOSIS

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DAYS

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ADVICE / REMARKS

Signed by Dr. Anita Rao · Gen. Medicine