Collation of OPD Data for PLA book draft

May 29, 2023

Week -1

DAY 1 - MONDAY (29/03/23)

[5/29, 09:44] +91 77802 85086:

20210109238

52F

k/c/o pulmonary kochs with right upper lobe cavity with type 2 DM since 8 years on ATT drugs since 10 days, Zoryl MV 1 ( PO/OD)

patient came for follow up

c/o dry cough since 10fays

c/o vomitings 2-3 episodes , non bilestained , non projectile contains food particles since 10 days

decreased appetite since 10 days

No PICCLE

RS- trachea deviated to right side , on percussion dullness present decreased breath sounds on right supraclavicular and infraclavicular regions, infraclavicular crepts ( inspiratory )

advised for admission for further investigation, patient will admit after 2 weeks

[5/29, 09:45] Dr. Rakesh Biswas GM: Please share her case report and PaJR group link from her last admission

[5/29, 09:47] Dr. Rakesh Biswas GM: AsK her to keep updating her hourly activities (energy expenditure) and food plates (energy intake) daily in her PaJR group. Teach her how to do it keeping herself deidentified

[5/29, 09:52] +91 6303 667 948: Follow this link to join my WhatsApp group: https://chat.whatsapp.com/K7CO7ov38WJKmrtfRjD5Ii

[5/29, 09:57] Dr. Rakesh Biswas GM: PLA R: Chronic abdominal pain spectrum and the clinical case report as the most valuable test in the opd

https://chat.whatsapp.com/EPoN2j2P5wcE4cDZc7Gk8D

[5/29, 9:48 AM] Muskaan Goyal 2017 Kims: Sir I have taken the detailed history' with daily routine of the patient before illness ..i will type it into a case history and put in a while

[5/29, 9:49 AM] Rakesh Biswas: Sharing patient and institutional identifiers in social media 😳

[5/29, 9:50 AM] Rakesh Biswas: Delete this asap @⁨Lohith Sir GM⁩

[5/29, 9:52 AM] Rakesh Biswas: Good. Looking forward to that link which the patient should be able to appreciate as the best test report he has ever seen in his life!

Also add the images of his previous reports there.

Prepare the case report of every patient in the opd in this manner

[5/29, 9:53 AM] Muskaan Goyal 2017 Kims: Sir he doesn't have the previous reports..he apparently lost them

[5/29, 9:54 AM] Rakesh Biswas: OK no issues. Just write whatever he remembers about them in the history events

[5/29, 9:54 AM] Muskaan Goyal 2017 Kims: Okay sir

[5/29, 09:58] +91 77802 85086: 63M

20230546351

k/c/o DM since 3 years came for follow up on Tab.metformkn 500mg

Mason by occupation

c/o giddiness yesterday evening lasted for 5 mins relieved after taking rest

,came for regular check up of his sugars in view of giddiness

H/o heart disease (unknown) since 4 years used medication for about 1-2 months then stopped

no postural drop , supine - 100/60 standing 90/70

rombergs negative

dix hallpike negative

cVs- no murmurs,s1,s2+

[5/29, 10:02] Muskaan: 20210114280

31/F

Pt is a k/c/o Hypothyroidism since 6 months and is on Tab. Thyronorm 12.5mg /Po/OD came for follow up

C/o hairfall since 2years and weight gain since 3months

No c/o cold intolerance, difficulty in swallowing

N/k/c/o HTN , DM , CVA, CAD , TB ,asthma

CVS- S1 s2 heard , no added murmurs

RS - BAE+ NVBS heard

On pt request TFT advised

Advised for admission but ot is not willing aa she has to go for work.

[5/29, 10:08] Dr. Rakesh Biswas GM: AsK everyone to come back for the most important test, which is their meticulous case report. No tests will be ordered before that test

Don't do any tests on patient request without asking here @⁨Lohith Sir GM⁩ @⁨~Keerthi Madireddi⁩

[5/29, 10:09] Dr. Rakesh Biswas GM: Demonstrate today's update for her in this group hourly expenditure and inputs

[5/29, 10:09] +91 99081 59666: Okay sir

[5/29, 10:15] +91 77802 85086: 73 F

op no : 20230546756

c/o pain in left upper molar teeth 3 months back relieved by medication recommended by dentist for 10 days, the pain has recurred again radiated to left side of face associated with tingling sensation , tingling sensation in tongue ,nose

c/o restriction of movements in shoulder joint painful

o/ e , caries present in left upper molar and premolars

flexion : restricted up to 60 degrees

external rotation restricts and painful

abduction upto 15 degrees

adduction normal

Both active and passive movements restricted

rounded shoulder

no h/o trauma

bilateral knee pains since 2- 3 years

k/c/o DM since 20 years on voglibose and glimiperide and metformin

advised admission for further evaluation, not willing to admit, will come back after 2 days.

[5/29, 10:17] Dr. Rakesh Biswas GM: Clinical images, case report and PaJR please

[5/29, 10:17] Muskaan: 20230546734

22/F

Pt came with complaints of diffuse headache , intermittent type , severe associated with neck pain and nausea since 3 months

Headache present for 2-3 days a week which is disabling her daily routine , releived on taking painkillers .

No photophobia , earpain , cold , cough

N/k/c/o HTN , DM type 2 , CVA ,CAD , TB ,ATHMA

O/E :

No pallor

CVS: S1 s2 heard

RS: BAE + , no added sounds

BP: 90/60mmhg

Pt advised for admission, but is not prepared to admit now , willing to admit if symptoms don't subside.

[5/29, 10:19] Dr. Rakesh Biswas GM: Clinical images, case report and PaJR please

Tell them that the above is the most important test even after admission and they can get it done here as well

[5/29, 10:20] Dr. Rakesh Biswas GM: PaJR initiation checklist:

1) History sequence of events link in description box

2) Clinical images of visceral fat and muscle mass (preferably standing lateral and ap views)

3) Available Radiology of the patient's problem (anatomic diagnosis)

4) Available electrophysiology (physio-logic diagnosis)

5) Relevant blood and fluid biochemistry (biochemical diagnosis)

6) Representative image in the DP

7) Patient project description (each and every PaJR is part of a ProJR). ProJR is project journey record that contains many PaJRs

8) Title : Age, gender example 26M Involuntary movements (always mention duration), Telangana, PaJR

[5/29, 10:21] Dr. Rakesh Biswas GM: This group is to improve our OPD competences and performance through regular logging of every patient visiting us in the daily OPD by our interns and students. Senior residents posted to the OPD for that day will be responsible for supervising this daily there

https://manogynab87.blogspot.com/2023/05/collation-of-opd-data-for-pla-book-draft.html?m=1

For every opd patient shared here :

Please share their

Sequence of events beginning with the time they had absolutely no problems they can recall.

AsK what was their routine when they were perfectly alright

Next ask what happened to their routine once the disease took hold on their lives

Specifically ask which part of their hourly routine was disrupted

Ask them their current requirements from us like if we had to give them a single medicine which problem would they prefer it to address

Take their examination findings with images of visceral fat and muscle mass for everyone among other more specific findings

Prepare their problem list and perceived requirements list in order of priority

Formulate a plan for each one of the problem requirements you have listed

More here : https://sites.pitt.edu/~super1/lecture/lec53671/002.htm

[5/29, 10:42] Muskaan: 20230546813

18/M

Pt came with c/o bloating sensation since 5 days.

Aggravated after eating food especially after spicy food

Belching present since 4-5 days

No c/o regurgitation of food

N/k/c/o TB ATHMA CAV CAD HTN DM

CVS - S1 s2 heard

RS- B/L air entry + , no added sounds

Pt advised for admission but Willing to come.back if symptoms don't subside

Treatment given:

1. Advised to stop having spicy and oily food

2. Advised for lifestyle modification

3. Tab. Pan 40mg PO/ OD at 7 am ( before food) for 7 days

[5/29, 10:53] +91 77802 85086: 19F

20230546657

complaints of weight gain since 2 months 3 - 4kgs in 2 months

easy fatiguability since 2 months

palpitations ( grade 2)since 2 months intermittent , relieved after taking rest

patient was apparantly alright 4 months then she had complaints of weight gain , she approached a doctor , doctor recommended thyronorm 100 microgram, for normal tsh, decreased t3,t4 , for her hairloss and weight goin

on examination , palpable thyroid moving on deglutition

BP -110/70

Pr -96 bpm

Dx-factitious?

advised admission for her complete thyroid evaluation , not willing to admit .

[5/29, 11:25] Dr. Rakesh Biswas GM: Admission is advised not for laboratory testing but for a detailed clinical history taking and clinical examination reflected in the patient's deidentified case report and also to train them to share their daily activities and potential disease risk exposure in their PaJR groups

[5/29, 11:30] Dr. Rakesh Biswas GM: By 31'st may, all 2018 students taking the medicine practical exams as well as currently doing their internship will need to share a summary of their logged learning experiences in medicine department introduced through their unique personal practical patient experience narrative with detailed patient follow up data in links to their logged case report entries beginning with their very first practical patient experience when they had their first posting in medicine department and they initiated their logbook entries (into their online learning portfolios for the first time).

This is for their internal assessment toward final exam assessments as well as internship completion.

Sharing below a few samples already submitted that others may improvise on. Their unique individual work should be reflected and marks will be deducted if any kind of plagiarism is detected.

2018 submitted sample links in no particular order :

https://tellashruthi159.blogspot.com/2023/05/ajnd-project.html?m=1

https://lasyapriyacherukupalli26.blogspot.com/2023/05/my-experiences-with-general-cellular.html?m=1

https://nitishdampuru33.blogspot.com/2023/05/my-experiences-with-general-cellular.html

https://manogynab87.blogspot.com/2023/05/ajnd-paper-first-draft.html

https://alavaramyatulasitejasri11.blogspot.com/2023/05/as-keen-learner-i-want-to-share-some.html?m=1

https://kshitijsharmamyrollno192case1.blogspot.com/2023/05/my-experiences-with-general-cellular_26.html

[5/29, 12:03] +91 77802 85086: 45F

street vendor by occupation , works in a tea shop usually wakes up at 4 o clock does house hold chores and goes to shop , does cooking , she used to eat a lot of bajjis and drink lots of tea for 5 years, after she started having belching symptom and stopped eating .

complaints of neck pain and giddiness since 2 days aggravated on standing up , position variation, sitting up associated with nausea.

h/o giddiness 2 years back relieved by taking medication ,sudden onset intermitten in nature

history of gastritis 2 years ago on omeprazole

rombergs negative

no postural hypotension

Dix hallpike positive with no latency, left ear , rotational nystagmus +ve supine-120/80

standing bp -120 /80

treatment - epleys manoeuvre done

[5/29, 12:10] Muskaan: 20230546347

37F

Referal from opthalmology i/v/o vertigo

Pt c/o spinning sensation of head since 5 days , intermittent in nature

No h/o similar complaints in the past

No c/o buzzing sensation of head, earache , giddiness , nausea , positional change.

N/k/c/o HTN DM CVA CAD TB ATHMA

BP: 120/80mmhg

Dixhalpike method - negative

Cerebellar signs negative

Treatment given Tab.vertin 8mg PO/OD/ 8 am for 1 week

[5/29, 12:34] +91 77802 85086: 20230547355

50F

complaints of chest pain since 5 days,burning type, retrosternal radiating to back not associated with sweating sob,palpitations,syncopal attacks,

no h/o trauma

no local tenderness

bilateral pedal edema since 5 days pitting type until knees, facial puffiness present

no h/o decreased urinary output

on examination

no Piccl

no jvp

apical impulse lateral to mid clavicular line in 5th intercoastal space

clinical case of hypertension

since 5 years o telma40mg

clinical case of hypothyroidism since 5 years thyronorm 100mcg

patient advised for cardiac evaluation, willing to admit after 1 week .

[5/29, 12:52] Muskaan: 20230547409

25M

Pt came with c/o burning sensation in epigastric region since 1 year increased since 3 months

Increased burning after intake of food , intake of spicy food and oily food

Bloating present

Belching present

No regurgitation of food

No h/o vomitings , losse stools , constipation

Occasionally takes 1 beer , no increase in symptoms after intake of alcohol

CVS S1 s2 heard

RS: BAE+ no added sounds

BP: 120/80mmhg

Pt advised admission but Willing to admit if symptoms not subsiding.

Dx : acid peptic disease

Rx :

Avoid oily , spicy food

Tab. Razo-o po/before breakfast for 7 days

[5/29, 14:42] Dr. Rakesh Biswas GM: What is the efficacy of beta histine in vertigo? Any RCTs?

[5/29, 14:43] Dr. Rakesh Biswas GM: What do you mean advised cardiac evaluation!!?

What is your cardiac evaluation?

[5/29, 15:17] Muskaan: 20230547281

40F

Pt c/o productive cough with mucoid sputum since 10-15 days

Sputum yellowish in color

Cough is intermittent in nature

Burning sensation of chest present which aggravated after cough

Belching present

No h/o fever , cold

C/o neck pain since 1 year non radiating type

H/o lifting heavy weights present since 20 years

N/k/c/i HTN DM CVA CAD TB ATHMA

CVS: S1 s2 heard

RS : bilateral air entry present no added sounds

No exposure to dust and cold

Pt advised for admission , willing to come and get admitted tomorrow.

[5/29, 15:21] Muskaan: 20210427845

48M

C/o low backache since 3 days

Aggravated on bending down

H/o weight lifting since 20 years

H/o similar complaints since 2-3 years

K/c/o HTN since 7-8 months , on Tab. Telma 40mg /po/of

N/k/c/o DM CVA CAD TB ATHMA

O/E :

Mild tenderness present

Rx:

Avoid lifting heavy weights

Tab. Hifenac -MR for 3 days

[5/29, 15:22] Dr. Rakesh Biswas GM: Metapsych thesis bed number death May 2023

[5/29, 15:29] Muskaan: 20230547828

41 F

Pt came with c/o

Fever since 1 week

Generalized body pains since 1 week

Bloating and indigestion since 1 week

Fever sudden in onset , high grade , intermittent releived on medication and tepid sponging , no diural variation.

Not associated with vomitings

Abdominal pain present in umbilical region , increased on lifting heavy weights ( farmer by occupation)

C/ o constipation since 2 years

K/c/o abdominal TB 2-3 years back for which used medication for 1 year

H/o hysterectomy and appendectomy 5 years back i/v/o fibroid uterus and appendicitis

N/k/c/o HTN DM CVA CAD, pulmonary TB, ATHMA, epilepsy

CVS S1 s2 heard

RS BAE+

Pt advised admission and willing to admit tomorrow

[5/29, 15:34] Muskaan: 20230547841

53M

C/o SOB since 2 months

Sudden , progressed from grade 3 to grade 4 , orthopnea present , PND present

No h/o chest pain , palpitations

H/i pedal edema since 2-3 days , pitting type extending upto kneee bilateral

No h/o burning micturation, vomiting or decreased urine output

N/k/c/o HTN DM CVA CAD TB ATHMA

Uses Tab. Pan 40mg since 2-3 years i/v/o acid peptic disease

CVS S1 s2 heard

RS BAE NVBS heard

BP: 120/80 mmHg

Bilateral pitting type pedal edema present

JVP raised

Pt sent for ECG

[5/29, 15:40] Muskaan: 20230547874

40M

C/o abdominal bloating since 2 days

C/i decreased appetite since 10 days

C/o SOB since yesterday grade 3

Orthopnea present

PND present

Alcoholic since 13 years

First 10 years used to take occasionally

Since 3 years regular alcohol intake 90ml daily

K/c/o DM 2 since 3 years on Tab. Metformin 500mg po/bd

Hb: 6.6 gm/dl

Sr. Bilirubin -4.97mg/dl

Usg abdomen - hepatomegaly with grade 2 hepatic steatosis

B/l renal calculi ( non obstructive )

O/e ;

Icterus present

CVS S1 s2 heard

RS BAE NVBS heard

P/A : shifting dullness absent

Pt admitted in AMC

[5/29, 15:47] Muskaan: 20230547865

57M

H/o syncopal attack today morning for 2-3 mins

No loss of consciousness

Giddiness absent nausea absent

No headache , nystagmus , generalized weakness, dizziness

No involuntary movements present

C/o productive cough since 1 month with mucoid sputum

No c/o fever , cold

No h/o similar complaints in the past

N/k/c/o HTN DM CVA CAD TB ATHMA Epilepsy

O/e

CVS S1 s2 heard

RS BAE present no added sounds

Orthostatic hypotension present

( Supine - 120/70 mmHg

Post 3 mins - 90/60mmhg

Giddiness present at 2min)

Pt sent for ECG

[5/29, 15:51] Dr. Rakesh Biswas GM: This is an image of Bed number 3 taken right now,currently ascribed the bad name that has created a metapsychosis among staff who kept it empty most of the time this month. Good news about this bed today is that a patient who was admitted in bed 3 this Saturday got released to the ward yesterday Sunday 6 PM and is doing fine today. Another patient who got admitted yesterday Sunday at 11AM was allotted bed 6 (as bed 3 was occupied by the patient who is still living well) and he died in bed 6 at 2:48 PM . Notes from the metapsych thesis lab ICU

[5/29, 19:45] Dr. Rakesh Biswas GM: @⁨Lohith Sir GM⁩ How many seen and how many admitted today?

[5/29, 19:50] Lohith Sir GM: 30 were seen and 1 admission sir

DAY 2 - TUESDAY (30/5/23)

[5/30, 09:44] Dr. Rakesh Biswas GM: "Gradually, I began to see the source of my suffering. In bits and pieces, the program that had driven my life and ambitions revealed itself. I reached into the toolbox of techniques and methods I'd collected, finally applying them to the root of the problem instead of seeking to create a better version of myself. The most important insight was to see that our suffering comes from an inability to differentiate between:

1. Data

2. Narrative"

More here : https://therenegademethod.com/becoming-a-renegade/

[5/30, 10:17] +91 6303 667 948: 20230548191

30 M came to OPD with c/o chest pain since 1 mn. Dragging type of pain,sudden in onset, relieved automatically in 2 -3 mins,non radiating pain.

-SOB since 2 mins Grade 2( MMRC) releived by taking rest .

No orthopnea,NO PND

NO fever,cold,cough

NO pedal edema,JVP not raised

Past history -

N/k/c/o DM ,HTN ,ASTHMA ,TB, EPILEPSY

GENERAL EXAMINATION :

Pt is c/c/c

Moderately built and nourished

Vitals:

BP: 120/80 mmhg

PR: 82 bpm

RR: 16cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

[5/30, 10:44] Neha T KIMS: 20210111893

54 y/M came with c/o left shoulder pain since 20 days and chest pain since 20 days

Shortness of breath since 20 days, Grade 2 MMRC

Chest pain is sudden in onset, dragging type of pain, non radiating, lasts for 1 hour and relieved spontaneously

Left shoulder pain present on abduction

C/o dribbling of urine and hesitancy since 10 days

Past history: Not a known case of DMII, HTN,TB,epilepsy,CVA,CAD

O/E:

Patient is c/c/c

BP: 140/90 mmHg

PR: 88 bpm

RR: 16 cpm

No pedal edema, JVP not raised

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

[5/30, 10:53] Neha T KIMS: 20230548193

22y/F came with c/o headache since 6 months

Diffuse headache, pricking type of pain which lasts for 1 week a/w nausea but no vomitings

No photophobia

C/o Neck pain since 6 months

No restriction of movements

C/o tingling sensation of bilateral lower limbs since 6 months and tingling sensation of right hand while doing heavy work.

Past history: Not a known case of DMII, HTN,TB,epilepsy,CVA,CAD, thyroid abnormalities.

O/E:

Patient is c/c/c

BP: 110/70 mmHg

PR: 64 bpm

RR: 12 cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

[5/30, 11:03] Dr. Rakesh Biswas GM: This is the shortest duration of illness in the history of history taking!! @⁨Lohith Sir GM⁩ @⁨~Keerthi Madireddi⁩ Are we confusing months with minutes?

Please skip the negative narrative and save on your typing time

Just give us the positive data!

[5/30, 11:04] Dr. Rakesh Biswas GM: What happened after that @⁨~Basani Sravanthi⁩!!??

[5/30, 11:06] Dr. Rakesh Biswas GM: What happened next? What did you do?

[5/30, 11:08] +91 6303 667 948: SOB since 2 months **

[5/30, 11:36] Dr. Rakesh Biswas GM: 👆

[5/30, 11:40] +91 6303 667 948: Advised ECG sir

[5/30, 11:48] Dr. Rakesh Biswas GM: Show the ECg

[5/30, 12:06] +91 6303 667 948: 20230549098

70 M came to OPD with c/o burning micturition since 5 months , intermittent.

H/o fever 1mn back ? Dengue ? Low platlet count

H/o ? Renal infection ? CKD 5 months back used medication stopped since 1month.

Past history -

K/c/o HTN since 5- 6 years on medication.

N/k/c/o DM,ASTHMA ,TB, EPILEPSY

GENERAL EXAMINATION :

Pt is c/c/c

Moderately built and nourished

Vitals:

BP: 130/80 mmhg

PR: 60 bpm

RR: 16cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient is advised for admission,but not willing for admission.

[5/30, 12:07] Neha T KIMS: 20230549091

50y/F came to OPD with c/o right sided headache since 2 months.

Headache is on the right frontal side associated with nausea and vomiting.

No photophobia, phonophobia

Decreased sleep due to headache.

O/E:

Patient is c/c/c

BP: 100/80 mmHg

PR: 74 bpm

RR: 12 cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Advised: 1) T. NAXDOM 250 mg PO/BD X 5 days

2) T. ULTRACET 1/2 tab PO/QID

[5/30, 12:22] Neha T KIMS: 20230549125

57y/F came to OPD with c/o Shortness of breath since 15 days

SOB was grade 2, no orthopnea or PND

Palpitations present, pedal edema, pitting type since 2 days

JVP not raised, no decreased urine output

K/c/o Hypertension since 3 years on Tab. TELMA H

O/E:

Patient is c/c/c

BP: 130/80 mmHg

PR: 80 bpm

RR: 16 cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Advised admission, patient getting admitted under unit 2.

[5/30, 12:50] Neha T KIMS: 20210417751

37y/M came with c/o left loin pain since 1 week

Pain is pricking type, radiating to left iliac region, aggrevated on doing work and relieved automatically.

It is associated with burning micturition since 1 week

Associated with nausea but no episodes of vomiting.

No decreased urine output, no fever, cold or cough.

O/E:

Patient is c/c/c

BP: 110/70 mmHg

PR: 80 bpm

RR: 16 cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Advised for admission for investigations but patient is not willing.

[5/30, 12:57] +91 6303 667 948: 20230549131

80 M came to OPD with c/o grade 2 ,3 since 10 days, more on lying.

No wheeze

No pedal edema ,normal urine output.

? Vertigo ( on betahistin ,

On clonazepam, propranolol )

H/o 10 days back fever .

- ex smoker ( stopped 10 yrs back).

- drinks toddy occasionally.

Past history -

K/c/o HTN and DM since 8 years.

N/k/c/o,ASTHMA ,TB, EPILEPSY .

GENERAL EXAMINATION :

Pt is c/c/c

Moderately built and nourished

Vitals:

BP: 130/80 mmhg

PR: 102 bpm

RR: 20cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient is advised for admission, patient is getting admitted .

[5/30, 13:41] Neha T KIMS: 20230549631

65y/F came to OPD with c/o generalized weakness and giddiness since 4 days

Episode of (?)loss of consciousness for 5 minutes, 4 days back

Decreased appetite

No photophobia, no phonophobia

Past history: h/o epilepsy since 12 years on T. EPTOIN. Last episode 3 months back and then started on T. LEVIPIL 250 mg BD

H/o Left femur fracture with implant 9 months back due to fall after ?vasovagal syncope

O/E:

Patient is c/c/c

BP: 120/70 mmHg

PR: 80 bpm

RR: 16 cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission

[5/30, 15:08] +91 6303 667 948: 20230549173

55F came to OPD with c/o pedal edema (putting type ,SOB ( grade 4 ) since 5 days.

Decreased urine output, burning micturition since 5 days.

Dribbling of urine +

Past history -

N/k/c/oDM, HTN,ASTHMA ,TB, EPILEPSY .

GENERAL EXAMINATION :

Pt is c/c/c

Moderately built and nourished

Vitals:

BP: 130/80 mmhg

PR: 80 bpm

RR: 20cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient is advised for admission, patient is getting admitted .

[5/30, 15:32] Neha T KIMS: 20230549658

65y/M came with c/o burning sensation in both feet since 1 year

Low backache since 1 year

Giddiness since 2 weeks

Patient is a known case of hypertension since 4 years and on regular medication of T. AMLONG 5 mg PO/OD and T.ATENOLOL 50 mg PO/OD

Not a known case of DM, TB, asthma, epilepsy,CAD,CVA

O/E:

Patient is c/c/c

BP: 100/60 mmHg

PR: 78 bpm

RR: 16 cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

No nystagmus, no tinnitus

Patient adviced for admission but not willing.

[5/30, 16:07] +91 6303 667 948: 20230549656

39 F came to OPD with c/o headache right sided since 6 months. Pricking type of pain.

Nausea -

Vomiting -

Photophobia -

Phonophobia -

Past history:

H/o trauma to head (RTA).

No LOC,No involuntary movements

CT scan - ? Multiple calcified granulomatous lesion.( On levipil 250 mg BD).

N/k/c/oDM, HTN,ASTHMA ,TB, EPILEPSY .

GENERAL EXAMINATION :

Pt is c/c/c

Moderately built and nourished

Vitals:

BP: 90/70 mmhg

PR: 80 bpm

RR: 16cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient is advised for admission, but not willing for admission.

[5/30, 16:17] Dr. Rakesh Biswas GM: @⁨Lohith Sir GM⁩ opd stats?

[5/30, 16:20] Lohith Sir GM: Around 30 patients were seen and 4 admissions sir

DAY 3 - Wednesday ( 31/5/23)

[5/31, 10:29] Dr. Rakesh Biswas GM: https://chat.whatsapp.com/CqJ7L86neFV7gE2PUXVxjF

[5/31, 10:24 AM] Patient Adv 24F Diabetes Metabolic: Sir hum lok 2nambar gate ke bahar ha

[5/31, 10:24 AM] Patient Adv 24F Diabetes Metabolic: Kaha jay ab

[5/31, 10:26 AM] Rakesh Biswas: @⁨~Keerthi Madireddi⁩ @⁨Navya Maam Medicine⁩ This long distance patient's advocate is waiting outside gate number 2

Please help them to reach opd and get admitted asap in the ward of their choice

[5/31, 10:26 AM] Keerthi 2021 Kims Pg: okay sir

[5/31, 10:29] Dr. Rakesh Biswas GM: @⁨Lohith Sir GM⁩ @⁨~A.R.T.TEJASRI⁩ No patients seen till 10:30 AM?

[5/31, 10:50] Manasa Kims: Op no-12

19 years old girl came to the opd with c/o dragging type of pain in both lower limbs from knees to ankles since 2months

H/o giddiness in the past (on&off)

Patient walking a/w tingling and numbness in calf region since 2months

H/o headache (occipital region) on&off since 1month while reading ,driving ,exam, revelied on its own

No c/o lower back ache

N/k/c/o DM,HTN,Asthma,epilepsy, TB

O/E

Pt is c/c/c

Afebrile

PR-84Bp

RR-20cpm

Bp-120/80mmHg

Patient advised for admission but not willing to get admitted

[5/31, 11:05] Manasa Kims: Op no-8

29 years old malecame to the opd with c/o chest pain since 15days

, c/o lower abdomen pain since 2days on& off

Hopi- chest pain was shooting type lasts for 2-3min,non radiating ,aggravated on working,bending forward, relieved spontaneously without any medication

No c/o difficulty on breathing, chest heaviness,

No c/o burning mictirition; fever

N/k/c/o DM,HTN,Asthma,epilepsy, TB

Tenderness present in the 2nd ,3rd IC space

O/E

Pt is c/c/c

Afebrile

PR-94Bp

RR-20cpm

Bp-110/80mmHg

Patient advised for admission but not willing to get admitted

[5/31, 11:12] Dr. Rakesh Biswas GM: Please discuss every patient with the senior residents onsite and share here what they are advising to help the patients even if the patient doesn't want to get admitted

[5/31, 11:16] Manasa Kims: Op no-5

35 yrs old lady with c/o left lower backache radiating to left leg on&off since 1month , left lower limb swelling (after sitting for 2hrs)

C/o lower abdominal pain since 1yr

C/o burning sensation in the chest since 6months

C/o burning micturtion since 1month a/W LOWER BACK ache

No c/o chest heaviness, palpitations,chest pain

K/c/o hyperthyroidism since 2nd pregnancy 2018

N/k/c/o DM,HTN, asthma,epilepsy,CVD

O/E

Pt is c/c/c

Afebrile

Bp 100/70

Rr-16

PR 78

Cvs - s1s2 present ,no murmurs

Rs- Bae+

P/a soft,non tender

CNS-nad

Patient advised for admission but not willing to admit

[5/31, 11:33] Manasa Kims: Op no-5

65 yrs old male with c/o lower back pain on both sides since 6yrs,dragging type ,intermittent,non radiating aggravated on working, no relieving factors.

C/o tingling sensation on face since 4years, c/o burning sensation in the sole since 4years

H/o vomiting 2days back3episodes ,non bilious, non projectile,food as content

No h/o fever,cough,cold,burning micturition

N/k/c/o DM,HTN, jasthma,epilepsy,CVD

Pt drinks alcohol stopped 20yrs back

O/E

Pt is c/c/c

Afebrile

Bp 130/80

Rr-14

PR 80

SLRT -ve

Para spinal tenderness +

Diagnosis :-?musculosketal

I/v/o gastritis , paraesthesia of face &sole ,Patient advised for admission but not willing to admit

[5/31, 11:45] Manasa Kims: Op no-17

80 years old male with c/o difficulty in breathing, chest tightness after eating since 15days

Decreased appetite since 15days

Generalized weakness since 15days

No c/o fever,cough cold,burning micturition,pain abdomen

N/k/c/o DM,HTN, asthma,CVD,epilepsy

O/e

Afebrile

130/80

14CPM

73bpm

Spo2 -96

Rs-BAE+,nvbs

P/a-soft, non tender

I/v/o sob, Patient advised for admission,but not willing to admit

[5/31, 11:55] Manasa Kims: Op no-19

32yrs old lady with c/o left side lower back ache since 20days, stabbing type, radiating to front , aggravated on working, no relieving factors

C/o burning micturition, increased frequency of micturtion since 15days

H/o right sided kidney stones 4months back

No c/o fever, cold ,cough,pain abdomen

C/o increased bleeding during menses since 4months

N/k/c/o DM,HTN,asthma,epilepsy,CVD,thyroid

Pallor +

SlRT-ve

Paraspinal tenderness +

I/v/o further evaluation of lower back pain patient advised for admission but not willing to admit

[5/31, 12:11] Manasa Kims: Op no -16

55yrs old male with c/o altered behavior ,slurring of speech since morning 9am

Patient had done his own work in the morning

C/o left lower limb weakness since morning

c/o cough not a/w sputum

K/c/o HTN since 3years on medication

N/k/c/o DM,asthma,epilepsy

Bp-130/70

Gcs - E4v2m6

Aphasia

Hypotonia left lower limb

Reflexes except ankle other +++

Left Lower limb muscle power -0/5

Patient advised for admission,they are willing to admit

[5/31, 12:24] Manasa Kims: Op no-16

18 yrs old boy with c/o headache since 2weeks,b/l band type of headache, continuous,aggravated on usage of phone,relieved on medication a/w dragging type of pain in neck

NoH/o photophobia,phonophobia,vomitings, nausea,giddiness,sleep disturbance

C/o difficulty in breathing at night since 2days

No c/o fever,cold,cough

N/k/c/o DM,HTN,asthma,tb,epilepsy

Bp-110/80

PR-80

RR-14

Diagnosis -headache secondary to stress,?inadequate sleep

Patient advised for admission but not willing to admit

[5/31, 12:34] Manasa Kims: Op no-30

34 years old male with c/o upper abdominal pain ,chest tightness,back pain since 2days

Pain in epigastric region ,shooting type,radiating to left side of chest and left shoulder,aggravated on bending forward,not relieved on medication

Chest tightness a/w sob on walking for 1hr

Palpitations +

No c/o fever,cold,vomiting,burning micturition

N/k/c/o DM,HTN, asthma,epilepsy,cvd

O/e

Bp-100/70

PR-78

Rr-14

P/A - soft, tenderness + in epigastric region

Rs-bae+,nvbs

Patient advised for admission I/v/o sob, pain abdomen but not willing to admit

[5/31, 12:52] Manasa Kims: Op no -22

37 years old female with c/o pain in left upper limb since:4 day's.

Dragging type of pain ,aggrevating on working,

C/o burning micturition.

H/o Hypothyroidism since 9 yrs.

On regular medication thyronorm 75mcg.

N/k/c/o DM ,Htn,asthma,epilepsy,CVD

O/E

Tenderness + in forearm.

B.P: 120/70 mmHg

PR: 78BPM

CVS: s1s2 +

CNS: NAD

Rs:BAE+,NVBS +

P/A: soft,nT

Patient advised for admission but not willing to admit

[5/31, 13:13] Manasa Kims: Op no - 29

A 38 year old male came with c/o chest pain and pain in the upper abdomen since 4 months

*Retrosternal burning sensation,neck pain, dyspnea since 4 months

K/c/o hypertension since 5 years and on regular medication

N/k/c/o DM, thyroid disorders,asthma, epilepsy, CVA,CAD.

O/E :

Pt is c/c/c

PR:84bpm

BP: 140/70 mmHg

RR:18 cpm

CVS : S1S2 +

CNS: NAD

RS: BAE+,NVBS+

P/A : soft, tenderness + in epigastric region

Patient advised for admission but not willing to admit

[5/31, 14:41] Manasa Kims: 40 years old lady with c/o headache since 1month ,B/L,pricking type,intermittent (on&off),no aggravating &relieving factors.

C/o neck pain since 1month(dragging type)

No c/o photophobia, phonophobia,nausea,vomitings

Sleep disturbance +

C/o pedal edema since 1week ,pitting type,a/w puffiness of face on the morning,relieved later

No h/o decreased urine output,burning micturition,sob,fever

N/k/c/o HTN,DM, epilepsy,CVA,cad,thyroid

O/E

Pallor+

BP-120/70 (supine)

120/70(standing)

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,non tender

CNS -NAD

Patient advised for admission but not willing to admit

[5/31, 14:59] Manasa Kims: 28 years old male with c/o nausea since yesterday

Appetite normal

Weakness +,easyfatiguability+

C/o fever low grade since yesterday

No c/o ,cold,cough,pain abdomen, vomitings

Similar complaints present 1week back

C/o body pains since 2-3days

C/o pain abdomen since yesterday morning(Right hypochondrium,rt&Lt iliac fossa, right lumbar ,epigastric region)

N/k/c/o HTN,DM,thyroid,asthma,epilepsy,CVD

O/E

Pt is c/c/c

A febrile

Bp-110/70

PR-74

Rs-bae+,nvbs

P/a -soft, tenderness + in Right hypochondrium,rt&Lt iliac fossa, right lumbar ,epigastric region

CNS -NAD

Patient advised for admission i/v/o pain abdomen but not willing to admit

[5/31, 15:06] Priyarsha 2k18 Kims: A 19 year old male came with c/o headache which is b/l in occipital region since 5 days

Generalized weakness since 1 month

N/H/O aura,photophobia,

Phonophobia.

H/o significant weight loss ( 8 kgs in 6 months)

Appetite - normal

N/H/O fever, cough,sob

H/o easy fatiguability

N/H/O herbal medication

N/k/o DM,HTN,thyroid disorders, seizures

O/E

Pt is c/c/c

Afebrile

PR: 82/min

BP:100/60 mmHg

CVS:S1S2+

CNS:NAD

RS:BAE+ NVBS +

P/A : soft,nt

Patient advised for admission but not willing to admit

[5/31, 15:12] Manasa Kims: 29 years old female with c/o epigastric & chest pain on left side since 3days, continuous ,dragging type, non radiating ,no aggravating &relieving factors

C/o heaviness in the chest,sob since morning

No h/o indigestion,dyspepsia,regurgitation,heavy sweating,vomitings,

C/o pain the scapular region since 3days

O/E

Tenderness + 2nd ICS, left shoulder joint

Pain +when abduction &external rotation .

Patient advised for admission but not willing to admit

[5/31, 15:24] Priyarsha 2k18 Kims: A 36 year old female came with c/o right upper quadrant pain since 10 days

Mass per abdomen in right hypochondrium.

Pain radiating to right shoulder

H/o ? hemangioma and cysts in the liver

H/o ocassional left flank pain radiating to groin and left lower limb

B/l Chest pain which is non radiating and tenderness is present on palpation

O/E:

Pt is c/c/c

Afebrile

PR:84 bpm

BP: 100/60 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,tenderness present in right hypochondrium

Patient advised for admission but not willing to admit

[5/31, 15:50] Manasa Kims: 38 years old female with c/o bleeding from gums since 1year, intermittent, not a/w pain,

A/w pus discharge, perioral itching

No fever,cold,cough

H/o bad odour from the mouth

C/o headache in fronal region & near eye brows since 3-4years on&off

Photophobia +

Phonophobia+

No h/o sob, pedal edema,giddiness

O/E

Tenderness +at frontal sinus ,maxillary sinus region

Patient advised for admission but not willing to admit

[5/31, 15:53] Priyarsha 2k18 Kims: A 42 year old female who is a K/c/o hypothyroidism since 4 years on Tab THYRONORM 150 mg po/od

c/o neck pain since 1 week radiating to upper limb

Itching sensation all over the body

N/h/o fever, cough,pain abdomen, vomiting,change in urine colour or stools

N/h/o headache,chest pain,sob

N/k/c/o DM thyroid disorders, HTN seizures

O/E:

Pt is c/c/c

Afebrile

PR:82bpm

BP: 130/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A : soft,nt

Patient advised for admission but not willing to admit

[5/31, 15:58] Priyarsha 2k18 Kims: A 40 year old female came with c/o headache since 5 months

Diffuse , dragging type of pain,aggregated on bright light and no relieving factors, radiating to neck on posterior side, associated with aura

No c/o fever, vomiting,cough,cold

Photophobia+

Phonophobia+

N/k/c/o DM,HTN,thyroid disorders,epilepsy,CVA,CAD O/E:

Pt is c/c/c

Afebrile

PR:73 bpm

BP: 110/70 mmHg

RR:14cpm

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,nt

Patient advised for admission but not willing to admit

[5/31, 16:11] Manasa Kims: 18 years old girl with c/o chest pain(left & right side).

Pain more after eating spicy food,dragging type, non radiating , relieved on medication

No h/o sob,pedal edema, palpitations,chest tightness, fever,cough,pain abdomen

N/k/c/o HTN,DM,thyroid,asthma,epilepsy,CVD

O/E

Pt is c/c/c

Afebrile

Bp-100/60

PR-68

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,non tender

CNS -NAD,HMF intact

Patient advised for admission but not willing to admit

[5/31, 16:23] Priyarsha 2k18 Kims: A 36 year old female came with c/o giddiness since 3 months rotational

Search This Blog

MEDICINE LOG BOOK BY MUSKAAN GOYAL - ROLL NO. 92

Collation of OPD Data for PLA book draft

Comments

Post a Comment

Popular posts from this blog

A 78YEAR OLD MALE WITH SHORTNESS OF BREATH, CHEST PAIN, B/L PEDAL EDEMA AND FACIAL PUFFINESS

Bimonthly Clinical Case Assignment 1

A 73 YEAR OLD MALE PATIENT WITH PEDAL EDEMA, SHORTNESS OF BREATH AND DECREASED URINE OUTPUT