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Interpret what is written
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Here is a full interpretation of the prescription from Dakshata Superspeciality Heart and Maternity Centre, Nagar Nigam Chowk, Begusarai:
Clinic / Doctors
| Dr. Amarendu Kumar | MBBS, MD (Medicine), DM (Cardiology) - Senior Interventional Cardiologist |
| Dr. Priyanka Raj | MBBS, MS (Obs & Gynae) - Expert in Infertility, High Risk Pregnancy, Laparoscopic Surgery |
Patient Details
| Field | Value |
|---|---|
| Name | Ranjan (Male) |
| Age | ~42 years |
| Weight | 106 kg |
| Date | 25/06/2024 |
| Address | Begusarai |
Presenting Complaints / History
- Obesity
- NAFLD (+) - Non-Alcoholic Fatty Liver Disease (confirmed)
- HTN (+) - Hypertension (confirmed)
- Atypical chest pain
- Bad sleep
Examination Findings
Vitals:
- Pulse Rate: 78/min
- Blood Pressure: 140/90 mmHg
ECG: Normal - no specific changes
ECHO (Echocardiogram):
- Normal LV (Left Ventricle) size
- LV function EF 60% (normal)
- Valves - OK
- RV/RA - OK
- Pericardium - OK
Chest: Bilateral clear (bilateral vesicular breath sounds)
CVS: S1, S2 heard; no murmur/rub
Systemic Review:
- Diabetes (DM): No
- Hypertension (HTN): Yes
- CVS disease: No
- CNS issues: No
- Bleeding: No
- Thyroid: Negative
Prescribed Medications
| # | Medicine | Dose | Timing | Duration |
|---|---|---|---|---|
| 1 | Cap. UpRise D3 (60,000 IU) | 1 cap weekly | - | 4 weeks |
| 2 | Tab. Sompraz D (40 mg) - Esomeprazole + Domperidone | 1 tab daily | 7 AM (empty stomach) | 15 days |
| 3 | Tab. Etizola Plus (10/0.5) - Etizolam for sleep/anxiety | 1 tab daily | At night (9 PM) | - |
| 4 | Tab. Cilacar M (10/50) - Cilnidipine + Metoprolol for BP | 1 tab daily | At night (9 PM) | - |
| 5 | Tab. Lipvas (10 mg) - Atorvastatin for cholesterol/NAFLD | 1 tab daily | At night (9 PM) | - |
Summary
This is a cardiology consultation for a 42-year-old obese male (106 kg) with hypertension, NAFLD, atypical chest pain, and poor sleep. His ECG and echocardiogram are normal with preserved heart function (EF 60%). BP is mildly elevated (140/90). He has been prescribed:
- A calcium channel blocker + beta-blocker (Cilacar M) for blood pressure control
- A statin (Lipvas) for cholesterol management and NAFLD
- A PPI + prokinetic (Sompraz D) likely for gastric symptoms
- An anxiolytic/sleep aid (Etizola Plus) for his sleep complaints
- Vitamin D3 supplementation (common in obesity)
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