                                                RUHSA DEPARTMENT, CMC, VELLORE
                                                                                                                                              No. 2291
                                                         CASUALTY/IP REFERRAL FORM


                                                                                          Age: 23                                            Gender : (Male Y Female
  Name: SANJAY.S
                                                                                                                                                  Area y Out of Area
   Address: Kilmultukkare




   Hospital Number                      : AB67323

   Date                                 : 1119/23
                                                                                                                                            : 7: 00 AM/PM
                                                                                         Time of Referral
   Time of Arrival                      : 4:35 AM PM

   History of Presenting illness :
                      Fever x5 days - Not documented, ass/w chills

                        vomiting x 4 days - 4 - 3 episodes

    Co-Morbidities : No Co-morbs.

   Examination :
                                                                                                                                ADDITIONAL EXAMINATION
                   VITALS                                                   SYSTEMS
                                                                                                                                                  FINFINGS

     Pulse : 64/neu                                 CVS : SI S2 0 , nommenul

     BP           :96/60mmgHg
                                                     RS : NUBS, Ble equal an entry
     Temp : 97%


     SpO2 : 100%                                    Per Abdomen : soft, non cender, No
                                                                                    organomegaly
    GCS : 15/15
                                                 CNS : NFND
  GRBS :

                                     CBC -                                            urine - WBC-10-15
                                                WBC - 2700
 Investigations                                  Hb - 15.2
                                         :                                                                  Fact - coarse granular cast present
                                                    Pt-28000

  Treatment given
                                         :
                                                                               Patient vitally stable.
                                                HE Nil




                                                Fever with thrombocytopenia, propable Dengue
 Provisional Diagnosis :

 Reason of Referral                     : For fullse management

 Referred to                             .CMC/GYMCH/Gudiyatham GH/ Other : Specify

 Medical Legal Case : Yes                                      1/ No Z

If Yes (Specify)

Details of MLC (attach MLC Form) :


                                         Burg
                                                                                                                            84922
                                                                                          Registration / Employment No :
Doctor's Signature

                                                                                                                                       2023.09.16 09:46

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