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This is a handwritten medical prescription and clinical notes from Dr. G. M. Bhat, MBBS, practicing in Mujgund, Srinagar. The patient is Zaamin Tergam, seen on 15-6-26 (June 15, 2026). Here is a full breakdown:
Patient History (top right)
- Complaints: Pain in legs and hands (Pi - legs 2 hands)
- Decreased appetite (APA - decreased Appetite)
- History of jaundice 2 years back
- O/E (On Examination): Icterus (yellowing of eyes/skin) present
- Sub H (subclinical hepatitis markers noted)
- Chest, CVS, Abdomen examined
- BP: 90/60 mmHg (low blood pressure)
Lab Results (right side, dated 11-6-26)
LFT (Liver Function Tests):
- T. Bilirubin: 2.42 mg/dL (elevated - normal <1.2)
- ALT/AST/GGT: 29/33/136 (GGT significantly elevated)
- PT/INR: noted as "N" (normal)
KFT (Kidney Function Tests):
- Urea: 26
- Serum Uric Acid: 6.4
- Creatinine: 0.99
Lipid Profile: 163/393/457/456 (Total cholesterol/components - cholesterol and LDL appear elevated)
TFT (Thyroid Function Tests): WNL (Within Normal Limits)
TSH: Normal
CBC (Complete Blood Count): 13.1 / 52.3-42.3 (Hb ~13.1 g/dL), WBC ~5300, Platelets 120 (low - thrombocytopenia)
First Visit Prescription (15-6-26, left side)
| # | Medication | Dose/Frequency |
|---|---|---|
| 1 | Cap Pan D (Pantoprazole + Domperidone) | 1 cap once daily (OD) |
| 2 | Tab Nucate 4u (likely Silymarin/Liv-52 variant or hepatoprotective) | TID-BBF (three times daily, before breakfast) |
| 3 | Tab Cypon 4 (Cyproheptadine - appetite stimulant) | ½ tab OD at 8 PM |
| 4 | Tab Coumrant F | 1 OD |
| 5 | Betonin AST (B-complex/multivitamin) | 250 mg BD before meals |
| 6 | Tab CynoLiv 300 | 100 caps - 10-day supply |
Follow-up in 28 days (noted as "-28/00" and signature dated 15/6)
Follow-up Visit (28-6-26 - today's date)
Impression noted: "My & Jo... Intraprehensible" (possibly "Myalgia and joint pain - Hepatitis-related")
Circled: A.r (possibly Arthritis/Arthralgia)
New prescriptions added:
| # | Medication | Dose |
|---|---|---|
| 1 | Tab Dalvaz-F-AT (likely Diclofenac + Paracetamol - pain relief) | As directed |
| 2 | Tab Susbec XT OD (likely Pantoprazole or gut protector with extended release) | Once daily |
| 3 | Syp Solu (Syrup - possibly liver tonic/supplement) | 10 ml twice daily (bdgm = bis die = twice daily) |
Tests Ordered (bottom left)
- HBsAg - Hepatitis B surface antigen test
- Anti-HCV - Hepatitis C antibody test
These are being ordered to rule out viral hepatitis (Hepatitis B and C), which is consistent with the clinical picture - jaundice 2 years ago, currently elevated bilirubin and GGT, icterus on exam, and low platelets (which can suggest liver disease/portal hypertension).
Clinical Summary
The patient likely has chronic liver disease, possibly viral hepatitis (B or C), presenting with:
- Jaundice (past and current icterus)
- Elevated liver enzymes (bilirubin 2.42, GGT 136)
- Low platelets (120,000 - suggestive of hypersplenism from liver disease)
- Joint and muscle pain (arthralgia/myalgia - can be extrahepatic manifestation of Hep C)
- Loss of appetite
The doctor is working up for hepatitis B and C as the underlying cause, and managing symptoms with hepatoprotectives, appetite stimulants, and pain relief.
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