Sample Arogya Note
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Patient Consultation Summary
AI-GeneratedPatient NameRajesh Kumar
DateOctober 13, 2025
DoctorDr. Priya Sharma
Age/Gender45 years / Male
Visit TypeFollow-up
DiagnosisType 2 Diabetes
💬Why You Visited
You came in today because you've been feeling very tired lately and noticed increased thirst and frequent urination, especially at night.
🔍What We Found
Diagnosis: Type 2 Diabetes with blood sugar levels that need better control.
What this means: Your body is not using insulin properly, which causes sugar to build up in your blood instead of being used for energy. This is why you feel tired and thirsty.
Test Results:
- Fasting Blood Sugar: 185 mg/dL (Normal: 70-100 mg/dL)
- HbA1c: 8.5% (Target: Below 7%)
- Blood Pressure: 138/88 mmHg (Slightly elevated)
📋Your Treatment Plan
We're making some changes to help you feel better and get your blood sugar under control:
- Adjusting your diabetes medication to work better
- Following a healthier eating plan (details below)
- Adding 30 minutes of walking daily
- Monitoring your blood sugar at home
💊Your Medications
Metformin 500mg
Blood Sugar Control
⏰WHEN TO TAKE
Twice daily - After breakfast and dinner
🍽️WITH FOOD
Always take with meals
🎯PURPOSE
Helps your body use insulin better and lowers blood sugar
📅DURATION
Continue for 3 months
⚠ Important Things to Know:
- ⚠May cause mild stomach upset initially - this usually improves in a few days
- ⚠If you miss a dose, take it as soon as you remember, but skip if it's almost time for the next dose
- ⚠Don't double the dose
Glimepiride 2mg
Blood Sugar Control
⏰WHEN TO TAKE
Once daily - Before breakfast
🍽️WITH FOOD
Take 30 minutes before your first meal
🎯PURPOSE
Helps your pancreas produce more insulin
📅DURATION
Continue for 3 months
⚠ Watch Out For Low Blood Sugar:
- ⚠Signs: Sweating, shaking, dizziness, confusion, fast heartbeat
- ⚠If this happens: Eat 3-
- ⚠Always eat breakfast after taking this medicine
Atorvastatin 10mg
Cholesterol Control
⏰WHEN TO TAKE
Once daily - At bedtime
🍽️WITH FOOD
Can take with or without food
🎯PURPOSE
Protects your heart by lowering cholesterol
📅DURATION
Long-term medication
ℹ️ Good to Know:
This medicine works best when taken at night. It helps prevent heart disease and stroke. You may not feel any different, but it's working to protect your heart.
🥗Lifestyle Changes
Diet:
- Eat small meals every 3-4 hours
- Choose whole grains (brown rice, whole wheat) instead of refined grains
- Fill half your plate with vegetables
- Limit sweets, sugary drinks, and fried foods
- Drink 8-10 glasses of water daily
Exercise:
- Walk for 30 minutes daily after dinner
- Start slowly if you're not used to exercising
- Wear comfortable shoes
📅Next Steps
Blood Tests Needed:
- Fasting Blood Sugar - Weekly for 2 weeks, then monthly
- HbA1c - After 3 months
- Lipid Profile - After 3 months
Follow-up Appointment: In 4 weeks to review your progress and test results
Monitor at Home: Check your fasting blood sugar twice a week and keep a log
🚨 When to Contact Us Immediately:
- ⚠Blood sugar below 70 mg/dL or above 300 mg/dL
- ⚠Severe shaking, confusion, or loss of consciousness
- ⚠Extreme thirst or urination that gets worse
- ⚠Chest pain or difficulty breathing
- ⚠Severe stomach pain or persistent vomiting
✓ You Can Do This!
Managing diabetes takes time and effort, but you're not alone. With these medications, lifestyle changes, and regular monitoring, you can live a healthy, active life. Call us anytime if you have questions or concerns.
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