Collation of OPD Data for PLA book draft

June 5 , 2023

Week 2 

DAY 1- Monday ( 5/6/23)

[6/5, 10:04] Gauri 2k18 Kims: 20230604535

A 50 year old male came with C/o pain in the left side of chest since 2 days 

Pain is of pricking type, radiating to left shoulders 

Giddiness +

Sweating +

No palpitations and SOB

H/o alcohol consumption and smoking. (Stopped 1 year back) 

K/c/o HTN since 1 year. Patient is on medication 

N/k/c/o DM ,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 82bpm

BP- 120/80mmHg 

 RR- 17cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS:NFND  

ECG normal 

Treatment - 

Tab. Pantop 40 mg OD x10days 

Syp. Sucralfate 10 ml PO/TID

Pt adviced for admission and pt is not willing to get admitted 

Seen by 

Dr. Nithin(PGY2)

[6/5, 10:06] Gauri 2k18 Kims: 20210110981

A 74 year old male came with C/o headache in the frontal region since 15 days

Pain is lasting throughout the day and relieved by taking medication 

Photophobia +

Phonophobia +

K/c/o HTN since 15 years. Patient is on medication (Tab. Amlodipine 5mg) 

K/c/o DM since 15 years. Pt is on medication (Inj. HAI and NPH)

N/k/c/o Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 84 bpm

BP- 140/80mmHg 

 RR- 17cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS:NFND  

Pt adviced for admission and pt is willing to get admitted 

Seen by 

Dr. Keerti (PGY2)

[6/5, 11:17] Gauri 2k18 Kims: 20230604958

A 47 year old female came with C/o productive cough since 15 days

Cough associated with whitish mucoid sputum , increased in exposure to cold air 

C/o fever since 10 days. 

Low grade, intermittent , not associated with chills and rigor 

SOB after cough + 

No chest pain, palpitations

Belching + 

Pain in epigastric region after eating food 

No c/o throat irritation and throat pain

N/k/c/o HTN, DM,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 75bpm

BP- 120/80mmHg 

 RR- 16 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS:NFND  

Pt adviced for admission and pt is not willing to get admitted 

Seen by 

Dr. Keerti (PGY2)

[6/5, 11:18] Gauri 2k18 Kims: 20230604966

A 49 year old female came with C/o chest pain since 3 days

Pain is radiating to left shoulder since 3 days

No sweating, SOB, palpitations 

C/o left lower limb pain

K/c/o DM since 3 years. Pt is on regular medication

N/k/c/o HTN, Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 75bpm

BP- 120/80mmHg 

 RR- 16 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS:NFND  

Pt adviced for admission and pt is not willing to get admitted 

Seen by 

Dr. Keerti (PGY2)

[6/5, 11:18] Gauri 2k18 Kims: 20230604937

A 70 year old male came with C/o pain abdomen since 2 months 

Pain is in the epigastrium, intermittent and non radiating type

No belching 

No sweating, SOB, palpitations 

N/k/c/o HTN, DM, Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 75bpm

BP- 120/80mmHg 

 RR- 16 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS:NFND  

Pt adviced for admission and pt is not willing to get admitted 

Seen by 

Dr. Keerti (PGY2)

[6/5, 11:21] Gauri 2k18 Kims: 20230605545

A 31 year old female came with C/o fever with 2 days. 

High grade fever with chills and rigor, sudden in onset and relieved on taking medication. 

No cough, cold , nausea and vomiting 

Headache +

Body pains +

No h/o burning micturition 

Decreased appetite since 2 days 

SOB not present 

K/C/o hypothyroidism since 12 years. Pt is taking thyronom 50 mcg 

N/k/c/o HTN, DM,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 70 bpm

BP- 120/80mmHg 

 RR- 16 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS:NFND  

Pt adviced for admission and pt is not willing to get admitted 

Seen by 

Dr. Keerti (PGY2)

[6/5, 11:24] Gauri 2k18 Kims: 20230605005

A 65 year old male came with C/o fever with 15 days. 

High grade fever with chills and rigor and intermittent

H/o vomiting, 1 episode, bilious, watery and non projectile 

C/o generalised body weakness and body pains 

Pedal edema present initially, now relieved 

SOB grade 2 +

h/o burning micturition 

N/k/c/o HTN, DM,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 80 bpm

BP- 110/70 mmHg 

 RR- 16 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS:NFND  

Pt admitted under GM unit 1

Seen by 

Dr. Nitin (PGY1)

[6/5, 11:27] Gauri 2k18 Kims: A 82 year old female came with C/o knee pain, wrist and shoulder pain since 10 days 

Rash from knee to ankle +

Fever since 10 days , low grade, continuous, relieved on medication 

Cold and cough absent 

Pedal edema since 10 days , pitting type, extending upto ankle

Decreased urine output since 3 days 

K/C/o HTN since 10 years. Pt is on Telma AM 40 mg 

N/k/c/o, DM,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 80 bpm

BP- 110/70 mmHg 

 RR- 16 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS:NFND  

Pt admitted under GM unit 1 in SS ward 

Seen by 

Dr. Keerti (PGY2)

[6/5, 11:30] Gauri 2k18 Kims: 20230605495

A 35 year old female came with C/o tingling sensation in lower lip since 1 week 

No pain, no swelling, no fever 

Normal urine output 

N/k/c/o HTN, DM,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 68 bpm

BP- 120 /70 mmHg 

 RR- 14 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS: NFND

Pt advised for admission but Pt is not willing to get admitted 

Seen by 

Dr. Nitin (PGY1)

[6/5, 11:36] Gauri 2k18 Kims: 20230605542

A 42 year old female came with C/o epigastric pain since 5 days , burning type, intermittent 

Belching +

Decreased appetite +

Bloating +

No palpitations, chest pain, sweating 

N/k/c/o HTN, DM,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 78 bpm

BP- 120 /70 mmHg 

 RR- 14 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS: NFND

Diagnosis : ? Acute gastritis 

Treatment : 

Tab pantop 40 PO x 5 days

Syp Sucralfate 10 ml x 5 days 

Pt advised for admission but Pt is not willing to get admitted 

Seen by 

Dr. Kreeti (PGY2)

[6/5, 11:38] Gauri 2k18 Kims: 20230605030

A 47 year old female came with C/o epigastric pain since 6 months 

Non radiating , intermittent 

Belching +

No palpitations, chest pain, sweating 

N/k/c/o HTN, DM,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 74 bpm

BP- 120 /80 mmHg 

 RR- 14 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS: NFND

Diagnosis : ? Acute gastritis 

Treatment : 

Tab pantop 40 PO x 5 days

Pt advised for admission but Pt is not willing to get admitted 

Seen by 

Dr. Nitin (PGY1)

[6/5, 11:40] Gauri 2k18 Kims: 20230605006

A 34 year old male came with C/o tingling and numbness in b/l upper and lower limbs since 1 month

C/o pain in the B/l lower limbs since 1 month

Morning stiffness + (relieved after 30 mins)

Past history of Gout +

N/k/c/o HTN, DM,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 83 bpm

BP- 110/ 80 mmHg 

 RR- 14 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS: NFND

Pt advised for admission but Pt is not willing to get admitted 

Seen by 

Dr. Keeti (PGY2)

[6/5, 11:43] Gauri 2k18 Kims: 20230604967

A 38 year old female came with C/o left loin pain and left lower limb since 2 month

No cough and cold 

C/o SOB+ intermittent , grade 1-2 

No fever 

Chest pain + intermittently 

K/C/o HTN since 2 years. Not taking medication since 8 months 

N/k/c/o DM,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 80 bpm

BP- 110/ 80 mmHg 

 RR- 18 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS: NFND

Pt advised for admission but Pt is not willing to get admitted 

Seen by 

Dr. Keerti (PGY2)

[6/5, 11:47] Gauri 2k18 Kims: 20230604985

A 15 year old female came with C/o cough since 20 days, non productive 

No fever, loss of weight , loss of appetite 

No SOB

N/k/c/o HTN, DM,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 70 bpm

BP- 120/ 80 mmHg 

 RR- 16cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS: NFND

Treatment : 

Syp Ascoryl D 10 ml PO/TID

Pt advised for admission but Pt is not willing to get admitted 

Seen by 

Dr. Keerti (PGY2)

[6/5, 14:36] Muskaan: 20230604986

66yr old male pt came with c/o fever since 10days high grade associated with chills and rigors relieved on taking medication.

No H/o nausea , vomitings

Loose stools present 3 episodes / day very small volume, pus in stools present,solid consistency.

Pain abdomen present relieved on passing stools.

No H/0 cold,cough,headache,sob,body pains 

Not a k/c/0 htn,dm,tb , epilepsy.

Personal H/o:

Alocholic since 30years 90ml/ day

Stopped taking alochol since 10days.

Loss of appetite present 

Vitals:

bp:90/60mmhg

Pr 60bpm

Patient was advised for admission and patient is getting admitted

Dr keerti mam

Dr Harika mam

[6/5, 14:38] Muskaan: 20230604990

A 60 year old female came with c/o multiple joint pain rt>lt involving PIP joints and elbow joints since 3 months

C/o dragging type of pain in shoulder radiating to rt side of arm since 3 days associated with Tingling and numbness 

No h/o wt lifting 

H/o trauma to rt arm 1 and half year ago 

H/O morning stiffness for 30min 

K/c/o HTN 

N/k/c/o DM ,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 86bpm

BP- 120/80mmHg 

 RR- 18cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS:NFND  

Joint movements slightly restricted 

Knee crepitus present 

No tenderness 

Swelling in PIP and DIP 

Spine tenderness present 

No para spinal muscle stiffness 

Diagnosis- osteoarthritis 

Pt adviced for admission and pt is not willing to get admitted 

Seen by 

Dr. Keerti PG2

[6/5, 14:46] Muskaan: 20230606088

36M

C/i abdominal distension since 2 days

Abdominal pain since 2 days

C/o pedal edema 2 days

Upper and lower limbs since 2 days

H/o SOB grade 2

No h/o palpitations, raised JVP , orthopnea, PND 

No h/o burning micturation, increased or decreased urinary frequency

No h/i diarrhoea, constipation.

N/k/c/o HTN DM asthma cva cad

Bp: 110/70mmhg

PR: 80bpm

CvS S1 s2 heard no murmurs

RS BAE NVBS heard

Pt advised for admission but not willing

Dr keerti PGY2

[6/5, 14:58] Muskaan: 20230606091

50M

C/o left hypogastric pain and epigastric pain since 1 year

Intermittent, no aggravating releiving factors 

Vomiting present now subsided

Usg: raised echogenicity of right kidney

Urine output normal

No burning micturation

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

CVS S1 s2 heard no murmurs

RS BAE NVBS heard

Bp: 130/90mmg

PR: 78bpm

Pt advised for admission but not willing

Dr. Keerti PG2

[6/5, 15:06] Muskaan: 20210203824

42M

C/o b/ pedal edema since 15 days aggravated on sitting releived on walking .a/w dull aching pain upon prolonged sitting.

No SOB , chestpain , palpitations, sweating

Urine output normal

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

CVS S1 s2 heard no murmurs

RS BAE NVBS heard

P/A : soft non tender , BS +

Bp:120/80mmhg

PR: 75bpm

Pt advised for admission but not willing

Dr. Keerti PG2

[6/5, 16:33] Dr. Rakesh Biswas GM: Also share the details of the patient with anemia, weakness, severe knee pain and inability to walk, we saw in the opd and admitted in 'ss ward. I was told that even her sister who has a similar problem will get admitted in the same ward. Please update about both of them @⁨+91 93985 87059⁩ @⁨Lohith Sir GM⁩ 

How many seen and how many admitted today?

[6/5, 16:58] +91 99081 59666: 42 patients seen , 4 got admitted sir

Day 2 - Tuesday (6/6/23)

[6/6, 09:43] Neha T KIMS: 20230606372

38y/F came with c/o Neck pain and giddiness on and off since 5 years 

tingling sensation on left upperlimb on and off since 3-4 months 

 The neck pain is radiating to right shoulder.

K/c/o Maturity onset diabetes of young (MODY-3) on Tab. GLIMI-M3 PO/BD since 15 years  

Past h/o Left acute emphysematous pyelonephritis

O/E:

Patient is c/c/c

BP: 90/60 mmHg (supine) after 3 minutes of standing: 90/60 mmHg

PR: 70 bpm

RR: 14 cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

No nystagmus, no tinnitus

Rhombergs: Negative 

Patient adviced for admission but not willing.

Dr. Lohith (PG y1)

[6/6, 10:16] Neha T KIMS: 20210210383

59 y/M came with c/o left ankle pain since 3 days.

Pain is pricking type aggrevated on walking and relieved on rest.

On examination, no swelling but local tenderness +

K/c/o Hypertension since 1 year on Tab. AMLONG 5 mg PO/OD 

Past history of UTI with Gouty Polyarthritis 

 O/E:

Patient is c/c/c

BP: 130/90 mmHg

PR: 84 bpm

RR: 14 cpm

Systemic:

RS - BAE + ,NVBS

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Pavan (PG y2)

[6/6, 10:28] Neha T KIMS: 20230606386

70y/M came with h/o giddiness yesterday resulting in fall. 

No loss of consciousness but acquired injuries to left side of chest. C/o left side chest pain since fall

Gives h/o Bilateral pedal edema on and off since 5 years 

h/o Bilateral knee pains since 2 years

Past history: h/o Nephrectomy done to left kidney 8 years back ?Staghorn calculus

H/o CAD, post PTCA status 7 years back 

O/E:

Patient is c/c/c

BP: 120/80 mmHg (supine) after 3 minutes of standing: 120/80 mmHg

PR: 68 bpm

RR: 14 cpm

Systemic:

RS - BAE + ,NVBS, b/l mild wheeze in IMA

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

No nystagmus, no tinnitus

Rhombergs: Negative 

Patient adviced for admission but not willing.

Dr. Pavan (PG y2)

[6/6, 10:31] Dr. Rakesh Biswas GM: What are the features suggestive of MODY3 in this  patient?

[6/6, 10:34] Dr. Rakesh Biswas GM: Please share visceral fat and biceps images of every patient

[6/6, 10:50] +91 88970 34054: 20230606790

67y/F came with c/o productive cough since 3 months.

Sputum is mucoid in consistency, intermittent and copious in amount. It is aggrevated after eating food.

A/w Low grade fever, especially early morning with chills and rigour

Decreased appetite +, Weight loss + 

C/o Pain in right hypochondrium on and off since 5 years. Dragging type

Past history: k/c/o Hypertension since 8 years on Tab. TELMISARTAN 40 mg + AMLODIPINE 5 mg PO/OD

K/c/o Diabetes Mellitus type 2 since 8 years on Tab. GLICAZIDE 30 mg + METFORMIN 500 mg

K/c/o Hypothyroidism since 8 years on Tab. Thyronorm 120 mcg PO/OD

O/E:

Patient is c/c/c

BP: 110/70 mmHg 

PR: 88 bpm

RR: 14 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 10:54] Neha T KIMS: Onset before the age of 25, sir?

[6/6, 10:56] Dr. Rakesh Biswas GM: @⁨~Ajay Kumar Reddy⁩ CAD to follow

[6/6, 10:57] Dr. Rakesh Biswas GM: And what about the Age in other types of MODY?

[6/6, 11:24] Neha T KIMS: https://www.ncbi.nlm.nih.gov/books/NBK532900/

Sir, according to this the age criteria of below 25 years and positive family history are common for all types of MODY

[6/6, 11:24] Neha T KIMS: 67y/M came with c/o cough since 10-15 days 

C/o fever since 10 days 

Cough is associated with sputum which is whitish and blood stained, aggrevated at night.

Fever is low grade, more during the morning, relieved on its own 

A/w weight loss since 1 month (according to patient: lost around 11 kgs in 1 month)

Past history: k/c/o Diabetes mellitus type 2, on medication Tab. METFORMIN 500 mg + GLIMIPERIDE 2 mg PO/OD

O/E:

Patient is c/c/c

BP: 100/70 mmHg 

PR: 90 bpm

RR: 14 cpm

Systemic:

RS - BAE + , right IMA: Crepitations and rhonchi heard, Right ISA: Rhonchi heard

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Outside xray showing right upper lobe consolidation 

Patient adviced for admission but will come back tomorrow for admission.

Dr. Lohith (PG y1)

[6/6, 11:26] +91 88970 34054: 20230606912

72 y/F came with c/o giddiness since 15days on lying in right or left lateral position 

No c/o giddiness on supine, standing, sitting positions.

No c/o ringing sensation in ear, ear pain, neck pain 

Past history:

K/c/o hypertension since 10years, on TAB.CINOD 10mg PO/ OD

Surgical history: underwent L4-L5 decompression with posterolateral fusion under GA done on 28/4/23

O/E

Patient is c/c/c

BP: 160/80 mmHg 

PR: 103bpm

RR: 15 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

No nystagmus 

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 11:31] Neha T KIMS: 20230606874

63y/F came with c/o loose stools 5-10 episodes since yesterday night 

C/o 1 episode of vomiting yesterday night.

Loose stools are watery in consistency, non bilious or blood stained

Vomiting was non bilious, non projectile, having food as content.

Past history: k/c/o Type 2 diabetes mellitus since 12 years, hypertension since 1 year, on medication.

O/E:

Patient is c/c/c

BP: 90/40 mmHg 

PR: 80 bpm

RR: 14 cpm

Patient advised admission and getting admitted under Unit II

Dr. Lohith (PG y1)

[6/6, 11:35] +91 88970 34054: 20230606908

62 y/M came with c/o generalised weakness since 1 month 

H/o fever 1 month ago for 2 to 3 days

C/o headache (on & off) diffuse,intermittent type, relieved on medication 

Pt is a smoker since 40 years

O/E

Patient is c/c/c

BP:130/70 mmHg 

PR: 70 bpm

RR: 16 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 11:48] +91 88970 34054: 20230606928

31 y/M came with c/o pain abdomen around umbilicus, right and left hypochondrium since 1 week, intermittent, dragging type.

c/o belching

O/E

Patient is c/c/c

BP:110/80mmHg 

PR: 80 bpm

RR: 18 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 12:13] Neha T KIMS: 20230606918

65y/M came with c/o Neck pain since 1 year

C/o giddiness since 6 months to 1year 

Giddiness is aggrevated on standing, walking and relieved on lying down 

A/w hearing loss since 1 year on the left side.

No c/o earache, buzzing sensation in ear

Past history: k/c/o Hypertension since 1 year on Tab. TELMISARTAN 40 mg + HYDROCHLORTHIAZIDE 12.5 mg 

O/E:

Patient is c/c/c

BP: 130/70 mmHg 

PR: 60 bpm

RR: 14 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient advised admission but not willing

Dr. Lohith (PG-y2)

[6/6, 12:19] +91 88970 34054: 20210224158

36 y/F came with c/o burning micturition since 10 days, low grade with chills, relieved on taking medication 

c/o fever since 10days

c/o pain abdomen after passing urine since 10days

c/o vomitings since yesterday (4 to 5 episodes) food as content, non bilious, non projectile

c/o loose stools since 2 days (4 to 5 episodes/day) relieved on taking medication 

O/E

Patient is c/c/c

BP:100/70 mmHg 

PR: 80 bpm

RR: 15 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 12:30] +91 88970 34054: 20230605545

31 y/F came with c/o fever since 2 days high grade associated with chills

c/o body pains, headache 

c/o decreased appetite since 2 days

K/c/o Hypothyroidism since 12 years on TAB.THYRONORM 50mcg

O/E

Patient is c/c/c

BP:100/80 mmHg 

PR: 80 bpm

RR: 18 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 12:30] +91 88970 34054: 20230607476

31 y/F came with c/o dysphagia since 2 to 3 months

c/o SOB(grade 2) since 3 years

c/o palpitations

K/c/o HTN since 3 years used medication but stopped taking medication 3months ago

K/c/o Hyperthyroidism since 2 years, on TAB.CARBIMAZOLE 10mg PO/ BD

O/E

Patient is c/c/c

BP:110/70 mmHg 

PR: 83 bpm

RR: 18 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 12:59] Neha T KIMS: 20210513141

28y/F came with c/o burning type of sensation in chest since 4 days 

The pain is burning type, radiating to back and aggrevated on eating food.

Past history: Not a k/c/o DM, HTN, asthma,TB, epilepsy,CAD,CVA, thyroid dysfunction

H/o spontaneous abortion 6 months back 

O/E:

Patient is c/c/c

BP: 110/80 mmHg 

PR: 70 bpm

RR: 14 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient advised admission but not willing

Dr. Pavan (PG-y2)

[6/6, 13:08] +91 88970 34054: 20230550453

28 y/M came with c/o cough since 4 days, productive 

c/o weight loss 52kg on 26/4/23, 48kg now

c/o generalised weakness and fatigue 

O/E

Patient is c/c/c

BP:120/70 mmHg 

PR: 80 bpm

RR: 18 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 14:48] +91 88970 34054: 20210524403

28 y/F came with c/o fever since 3 days, low grade, intermittent, relieves on taking medication 

c/o cough since 2 days, productive

H/o ear discharge at 3 months of age

O/E

Patient is c/c/c

BP:120/70 mmHg 

PR: 68 bpm

RR: 18 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 15:02] +91 88970 34054: 20230607963

35 y/F came with c/o neck pain since 1 week, dragging type, intermittent, non radiating 

c/o burning micturition since 1 week

O/E

Patient is c/c/c

BP: 110/80 mmHg 

PR: 84bpm

RR: 18 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 15:34] +91 88970 34054: 20230607441

55 y/F came with c/o chest pain since 6 months, radiating to back, continuous 

c/o palpitations, excessive sweating 

c/o fever since 3 days

c/o loss of appetite since 1 month

c/o dizziness since 3 months

O/E

Patient is c/c/c

BP: 110/70 mmHg 

PR: 80 bpm

RR: 13 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 15:34] +91 88970 34054: 20230607977

35 y/F came with c/o dysphagia, odynophagia

c/o pricking sensation in throat since 1 month, intermittent, occurs for 15min and then relieved spontaneously, aggravated after taking food 

c/o cough since 1 month, intermittent.

O/E

Patient is c/c/c

BP: 130/80 mmHg 

PR: 80 bpm

RR: 15 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 15:50] +91 88970 34054: 20230607419

57 y/M came with c/o epigastric pain since 1 year

c/o vomitings, constipation 

K/c/o HTN since 1 year

O/E

Patient is c/c/c

BP: 110/80 mmHg 

PR: 84 bpm

RR: 15 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. Lohith (PG Y1)

[6/6, 19:29] +91 93985 87059: 40 cases seen ......2 got admitted sir

Day 3 - Wednesday ( 7/6/23)

[6/7, 05:48] Dr. Rakesh Biswas GM: Thanks 

Please share what criteria went into your patient's diagnosis of MODY3

[6/7, 05:54] Dr. Rakesh Biswas GM: Out of 40 only 20 cases were shared here @⁨+91 93985 87059⁩ @⁨Lohith Sir GM⁩ 

@⁨Muskaan⁩ Can we classify each opd patient into broad groups?

[6/7, 06:00] Dr. Rakesh Biswas GM: Yesterday's summary:

Giddiness 1

Ankle pain 1

Giddiness 1

Cough 1

Cough 1

Giddiness 1

Diarrhoea 1

Weakness 1

Pain abdomen 1

Giddiness 1

UTI 1

Fever 1

Dysphagia 1

Chest pain 1

Cough 1

Fever 1

Neck pain 1

Chest pain 1

Dysphagia 1

Abd pain 1

[6/7, 06:01] Dr. Rakesh Biswas GM: 

Common Groups ( 6/7/23)

Giddiness 4

Cough 3

Chest pain 2

Dysphagia 2

Fever 2

[6/7, 08:40] Muskaan: Okay sir..will do it from today

[6/7, 10:12] Raveela Kims!: 55yr /M came with c/o tingling and numbness in b/l feet : 3 months

Generalised malaise present

N/H/O loss of sensations, slipping. H/o polyuria present. Weight loss present. 

K/c/o Dm type 2.

K/c/o cervical cord stenosis

On medication. 

T. Glycomet Trio 2 : Po/BD

T. Sitagliptin po /0D

O/E

Patient is c/c/c

BP: 130/80 mmHg 

PR: 80 bpm

RR: 15 cpm

Systemic:

RS - BAE + , no added sounds

CVS - S1S2 heard , no murmurs

CNS - NFND

P/A - soft and non tender.

Patient adviced for admission but not willing.

Dr. AjayPG1

[6/7, 10:21] Dr. Rakesh Biswas GM: Diabetes since when?

[6/7, 10:28] Raveela Kims!: 10 yrs. Sir

[6/7, 10:35] Raveela Kims!: C/o pain in B/ Lcalf muscles. 

 Peripheral pulses +

 ABPI more than 0.9

Patient has started a new OHA regime. 

Hba1c : 9

Patient is willing for admission for sugar levels monitoring.

[6/7, 10:46] Raveela Kims!: 60 yr /M came with 

C/o B/L pedal edema : 3 months.insidious onset, gradual in progression. Initially pitting later progress ed to non pitting type. 

Later developed ulcer in left upper limb

H/o cva. 

K/c/o HTN: Amlo 5 mg

N/k/c/o Dm, asthma epilepsy. 

O/E

Non pitting edema upto knee joint

Skin DryPeripheral pulses not felt

Temp: 98F

PR:85

B. P:120/70mn Hg

Cvs : s1s2 +

Rs: NvBs

P/A : soft, NT

CNS:NAD

Patient referred to surgery op i/v/o lymphatic obstruction.

[6/7, 11:35] Raveela Kims!: 40 yr/F came with c/o pain abdomen, squeezing type : 1 week . C/o lower back ache, non radiating to back . No decreased urine output facial puffiness, pedal edema:1 month

Decrease appetite since 1 month. 

N/k/c /o Dm, HTN, asthma, seizures, CAD.

O/E

Patient is c/c/c

B . P: 140/90 mmHG

PR:88bpm

Cvs:s1s2 +, Jvp raised.

RS: BAE +, NVBS +

P/A: soft, suprapubic, periumbilical,hypochondriac.tenderness present

CNS: NAD

 Patient advised for admission but not Willing.

[6/7, 11:36] Dr. Rakesh Biswas GM: What would surgeons do for non pitting edema?

[6/7, 11:37] Dr. Rakesh Biswas GM: The chappal marks itself suggests this is pitting

[6/7, 11:38] Dr. Rakesh Biswas GM: His lateral view of visceral fat and biceps would have been a useful clinical image

[6/7, 11:40] Dr. Rakesh Biswas GM: Inadequate history 

Please don't waste time in typing negative history 

What was her hourly routine before she developed the pain 

What happened to that hourly routine after she developed the pain?

[6/7, 11:48] Manasa Kims: 70 yrs/M with C/o left sided chest pain since 15days

No radiation of pain

H/o trauma by fall to the chest

Occasional giddness +

Generalized weakness +

No h/o hearing loss/tinnitus

Occasional sob on exertion 

No h/o wheeze,orthopnea ,pnd,palpitations ,pedal edemes

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

O/E

Pt is c/c/c

A febrile

Bp-90/70

PR-68

RR-20

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,non tender

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 11:58] Manasa Kims: 40 years old male with c/o pain abdomen since 20days

K/c/o Renal calculi under conservative management

Pain abdomen , epigastric region, insidious onset ,pricking type, non radiating ,relieved with medications

C/o chest pain since 20days

No c/o sob, palpitations, chest tightness, burning micturition.

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

O/E

Pt is c/c/c

A febrile

Bp-120/70

PR-84

RR-16

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft, tenderness present in epigastric region

No renal angle tenderness

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 12:00] Raveela Kims!: 37/F patient is a known case of hypothyroidism on medication. Tab. Thyronorm 100mcg

Anxiety + , palpitation+, 

Renal calculi + 1 yr back and treatment done conservatively. 

N/k/c/o Dm, Htn, asthma,

O/E

Patient is c/c/c

Afebrile

Fine tremors +

Goiter -

Pallor+

Pedal edema grade:2

Bp-90/70

PR-68

RR-20

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,non tender

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 12:27] Manasa Kims: 70 years old male with c/o right sided pain abdomen since 30days

Which was insidious in onset, Rt hypochondrium region,non radiating, squeezing type,intermittent, aggravated on bending forward ,relieved on rest

No h/o burning micturition, vomitings, loose stools, constipation

C/o B/L knee pains since 20days, relieved with rest

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

O/E

Pt is c/c/c

Pallor -absent

Pedal edema-absent

A febrile

Bp-110/70

PR-78

RR-15

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft, tenderness + in rt hypochondrium region

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 12:38] Raveela Kims!: 48/M came with c/o left sided chest pain radiating to arm dull boring type :yesterday night

No c/o sob, palpitation. 

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

O/E

Pt is c/c/c

Pallor -absent

Pedal edema-absent

A febrile

Bp-110/70

PR-78

RR-15

CVS- s1s2+,JVP raised, apex beat: 5 th ICS

Rs-bae+,nvbs

P/a -soft, tenderness + in rt hypochondrium region

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 14:43] Manasa Kims: 28 years old female with c/o burning sensation in the chest (on&off) since 2years

C/o difficulty in breathing after eating food since 1week

Bleching +

C/o generalized weakness since 1week

C/o pain in the chest

C/o burning micturition since 1week

No frequency/urgency/hesitancy

H/o similar complaints in the past

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

O/E

Pt is c/c/c

Pallor+

Afebrile

Bp-100/70

PR-68

RR-16

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft, tenderness + in suprapubic region

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 14:43] Manasa Kims: 32 years old male with c/o generalized weakness since 15days

C/o easy fatiguability since 15days

C/o abdominal pain after eating food since 15days

H/o fever since 10days , low grade , intermittent , a/w chills &rigor,relieved after 3days

C/o joint pains since 2years

Similar complaints 6months back

C/o muscle aches 

No c/o burning micturition, vomitings, loose stools, retro orbital pain, 

No c/o palpitations,chest pain

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

O/E

Pt is c/c/c

Pallor -absent

 Afebrile

Bp-110/70

PR-84

RR- 16

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,tenderness + in epigastric region

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 14:53] Manasa Kims: 45 years old female with b/l pedal edema since 1month more during 1week ,pitting type, extending to knee

No h/o puffiness of face, decreased urine output , SOB,giddiness,palpitations

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

H/o hair loss present

K/c/o HTN since 8yrs on regular medication Tab.TELMA 40mg po/od

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

O/E

Pt is c/c/c

Mild pallor +

A febrile

Bp-140/90

PR-82

RR-14

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,non tender

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 15:01] Manasa Kims: 44 years female with c/o swelling in the b/l ankles since 15days 

Increased towards the end of the day , decreases by morning after sleep

 C/o sensation in the feet

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

K/c/o bronchial asthma since 15years using inhalers alternate day

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

O/E

Pt is c/c/c

Pallor- absent

b/l Pedal edema +(grade3)

A febrile

Bp-110/70

PR-78

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,non tender

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 15:09] Manasa Kims: 44 years old female with c/o pain abdomen since 1week ,insidious onset, squeezing type, non radiating, relieved on medication

C/o lower back pain since 1week, squeezing type ,non radiating, aggravated on forward bending ,relieved on rest

No c/o fever, burning micturition, decreased urine output ,facial puffiness

 C/o b/l knee pains since 3years on nsaids

Decreased appetite since 1month

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

O/E

Pt is c/c/c

Pallor -absent

Pedal edema +

A febrile

Bp-140/90

PR-88

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,tenderness + in left hypochondrium, 

Suprapubic tenderness+

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 15:20] Manasa Kims: 34 years old male with c/o chest pain since 5day radiating to left arm

H/o palpitations since 2days

C/o pain abdomen since 3days ,insidious in onset, epigastric region, squeezing type, non radiating ,relieved with medication

 C/o headache (unilateral)since 3days, stabbing type,non radiating,relieved with medication

No c/o fever,burning micturition, chest tightness, sob,palpitations

H/o weight lifting in the past

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

O/E

Pt is c/c/c

A febrile

Bp-90/60

PR-72

RR -18

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft, tenderness + in epigastric ,umblical,hypogastrium regions

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 15:24] Raveela Kims!: 70 yr/M came with c/o pain abdomen squeezing type increased on bending towards rt side. Relieved at rest. No H/o trauma

No H/o difficulty in Micturition, passing stools

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

O/E

Pt is c/c/c

A febrile

Bp-100/60 mmHG

PR-72bpm

RR -18Cpm

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,Non tender

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 15:37] Raveela Kims!: 40Y/F came with c/o pedal edema upto ankle since 1 month. (On and off) , No aggrevating and relieving factors. C/ o puffiness of face 10 days(on and off) relieved on waking up. Exertional sob +, 

No Orthopnea , No PND 

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

O/E

Pt is c/c/c

Pallor +

B/L pedal edema +

A febrile

Bp-100/60 mmHG

PR-72bpm

RR -18Cpm

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,Non tender

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 15:49] Manasa Kims: 35 years old female with c/o cough since 1month , productive cough with whitish sputum ,not blood stained

C/o head ache ,unilateral frontal region ,non radiating ,stabbing type aggravated on sound exposure ,no relieving factors a/w nausea 

C/o loose stools since 2days , 4episodes per day, watery content, small volume a/w pain abdomen

 C/o pain abdomen since 3days ,left hypochondrium&lumbar, non radiating ,squeezing type,relieved on medication

No fever, vomitings, burning micturition, decreased appetite,cold

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

O/E

Pt is c/c/c

A febrile

Bp-100/60

PR-86

RR-16

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,tenderness + in left hypochondrium, lumbar region

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 15:54] Raveela Kims!: 30yr/M came with C/o Giddiness and black out since 15 days. 

Increased while standing from supine position for 2 _ 3 minutes. 

No H/o tinnitus, vertigo, Vomitings, blurring of vision. 

K/c/o HTN:2 yrs using Tab. Telma 40 mg

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

O/E

Pt is c/c/c

A febrile

Bp-100/60

PR-86

RR-16

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,tenderness 

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 15:57] Manasa Kims: 24 years old female with c/o loose stools since yesterday ,insidious onset, 3-4episodes per day ,watery content, not blood stained, large volume  

C/o pain abdomen ,epigastric & lumbar region ,squeezing type, non radiating , relieved with medication

No c/o fever , nausea,vomitings, chest pain , sob, cough

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

O/E

Pt is c/c/c

A febrile

Bp-120/70

PR-88

RR-16

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft, tenderness + epigastric & lumbar region

CNS -NAD

Patient advised for admission but not willing to get admit

[6/7, 16:05] Manasa Kims: 42 years old female with c/o indigestion since 1 week

Bleching+

Dyspepsia+

C/o generalized weakness since 3days

C/o easy fatiguability since 3days

No c/o fever, pain abdomen, vomitings,nausea, constipation

No h/o weight loss

H/o decreased appetite

 +

K/c/o denovo DM 2days back on medication

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

O/E

Pt is c/c/c

A febrile

Bp-110/70

PR-72

RR-16

CVS-s1s2 + present,no murmurs

Rs- Bae+,nvbs

CNS-NAD

P/A -soft,nontender

Patient advised for admission but not willing to get admit

[6/7, 16:12] Manasa Kims: 48 years old male with c/o burning micturition since 5days

C/o increased frequency of micturition since 5days

C/o bulky stools with fat 

No c/o fever, loose stools ,pain abdomen, sob, cough, loss of appetite

O/E

Pt is c/c/c

Pallor -absent

A febrile

Bp-110/80

PR-88

RR-14

CVS-s1s2 + present,no murmurs

Rs- Bae+,nvbs

CNS-NAD

P/A -soft,nontender

Patient advised for admission but not willing to get admit

[6/7, 16:20] Manasa Kims: 29 years old female with c/o cough , dry cough since 2days, on &off ,relieved with medication

C/o sneezing since 2days

No h/o allergy

No c/o pain abdomen, cold ,sob, fever, chest pain,chest tightness,

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

O/E

Pt is c/c/c

A febrile

Bp-110/70

PR-74

RR-16

CVS-s1s2 + present,no murmurs

Rs- Bae+,nvbs

CNS-NAD

P/A -soft,nontender

Patient advised for admission but not to get admit

[6/7, 23:15] Dr. Rakesh Biswas GM: How many seen and how many retained to be seen more?

[6/8, 08:16] +91 93985 87059: 36 seen & 2 admissions sir

[6/8, 10:05] Parvez KIMS: 07/06/2023

Common Groups 

Pain abdomen 5

Pedal edema 4

Chest pain 4

Cough 2

Day 4- Thursday (8/6/23)

[6/8, 09:48] Sahithi KIMS: A 60yrs male came with c/o left sided neck pain since 10days 

Dragging type of pain radiating down to the left arm ,left shoulder.

K/c/o Dm since 5yrs on tab metformin 500mg

Not a k/c/o Htn , thyroid,asthma,Cad,cva

O/E:

Restriction of movement present to left side of neck 

Tenderness present over the sternocleidomastoid insertion site 

Finger grasp normal

Pt is c/c/c

Temp: afebrile

Bp :100/70

Pr: 81bpm

Rr : 18cpm

Cvs: S1 s2 heard,no murmurs

Rs: BAE present,NVBS

P/A soft .non tender

CNS: NAD

Patient adviced for admission and not willing to get admit

.seen by

Dr.Harika( pg 1)

[6/8, 10:00] Sahithi KIMS: A 45yrs female came with c/o lower backache (loin pain) radiating to groin since 1week.

No tenderness

Nocturia + 

Polyuria+ 

No tingling and numbness

No chest pain ,no burning micturition, palpitations.

K/c/o Dm type 2 since 3yrs on tab Tenegliptin 20mg 

Metformin 500mg 

Not a k/c/o Htn, thyroid.

O/E

Pt is c/c/c 

Pallor present

Temp: afebrile

Bp: 90/ 60

Pr: 76bpm

Rr: 16cpm

Cvs: S1 s2 heard, no murmurs

Rs: BAE present NVBS

P/A: soft ,non tender

CNS: NAD 

Patient adviced for admission and not willing to get admit

Seen by 

Dr.Harika (pg 1)

[6/8, 10:20] Krupa Kims: A 52 yr old male came with complaints of epigastric pain since 10 days

Continuous dragging type pain non radiating no aggravating factors 

Relieved with antacids 

No h/o indigestion, dyspepsia, regurgitation 

K/c/o DM II since 5yrs on tab.sitagliptin 50mg 

Tab. Metformin 500mg 

N/k/c/o HTN , asthma 

O/E 

Pt is c/c/c

Temp:- 98.2f 

BP:- 120/80mmhg 

Pr:- 74bpm 

Rr- 18cpm 

Cvs- s1s2 heard, no murmurs 

Rs- BAE present NVBS

P/A - soft, non tender 

Cns- NAD

Patient adviced for admission and not willing to get admit 

Seen by 

Dr. Harika pgy1

[6/8, 10:38] Sahithi KIMS: A 30 year old female came with c/o headache and neck pain since 1month

Pain in the neck radiating both upper limbs

H/O nausea, generalised weakness 

Headache is diffuse not associated with blurring of vision .

Relieved on medication 

N/k/c/o HTN, DM ,Asthma, TB, Epilepsy , CVD

O/E: 

Pt is c/c/c 

Afebrile 

PR- 78bpm

BP- 120/70mmHg 

RR- 16 cpm 

CVS: s1,s2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS:NFND  

Pt adviced for admission and pt is not willing to get admitted 

Seen by 

Dr. Harika pg 1

[6/8, 11:07] Sahithi KIMS: A 30yrs old female came with c/o cough with suptum whitish in colour since 1month.

C/o significant wt loss

No h/o fever, Decreased appetite, burning micturition,loose stools.

Not a k/c/o Htn,Em, thyroid,asthma.

O/E

Pt is c/c/c

Pallor present

Vitals:

Temp: afebrile

Bp: 100/60

Pr: 86bpm

Rr: 16cpm

Cvs:S1 s2 heard, no murmurs

Rs: BAE + ,no added murmurs

P/A : soft ,non tender

CNS: NFND

Pt advised for admission and pt is not willing to get admitted

Seen by 

Dr.Harika pg 1

[6/8, 11:23] Krupa Kims: A 60yrs old male came with c/o SOB since 1 month 

Grade III , orthopnea present, PND - 

No c/o chest pain , palpitations 

C/o decreased urine output, urinary incontinence since 1 month, no burning micturition

C/o pedal edema , pitting type extending till knee since 1 month 

C/o constipation, no h/o pain abdomen 

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

O/E :- 

Pt is c/c/c 

Temp:- afebrile

BP:- 120/80mmhg 

Pr- 82bpm 

Rr- 16cpm 

Cvs- S1S2 heard no murmurs

Rs- BAE present NVBS

P/A - soft, non tender

CNS- NAD

Patient adviced for admission but not willing to get admit 

Seen by 

Dr. Harika pgy1

[6/8, 11:25] Sahithi KIMS: 45Yr old female came with c/o pedal edema upto ankle since 2 months. (On and off) .

C/ o puffiness of face 1 month (on and off) relieved on waking up.

No Orthopnea , No PND 

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

O/E

Pt is c/c/c

Pallor +

B/L pedal edema +

A febrile

Bp-110/60 mmHG

PR-78bpm

RR -18Cpm

CVS- s1s2+,no murmurs

Rs-bae+,nvbs

P/a -soft,Non tender

CNS -NAD

Patient advised for admission but not willing to get admit

Seen by

Dr.Harika pg 1

[6/8, 11:46] Krupa Kims: A 65 yrs old female came with c/o pedal edema since 3 months 

B/L pitting type , extending up to ankle 

SOB , grade 3 , since 2 months 

No h/o chest pain , palpitations, orthopnea, PND 

No c/o decreased urine output, burning micturition 

K/c/o HTN since 1 yr and on regular medication tab. Atenolol 25mg 

O/E 

Pt is c/c/c 

Temp:- afebrile

BP:- 130/70mmhg 

Pr- 76bpm

Rr- 16cpm 

Cvs- S1S2 heard no murmurs

Rs-BAE present NVBS

P/A - soft, non tender 

CNS-NAD

Patient adviced for admission and patient is not willing to get admit

[6/8, 11:55] Sahithi KIMS: A 26yrs old female came with c/o fever since yesterday night

Low grade not associated with chills and rigors

C/o headache diffuse type and throat pain ,cold 

No H/o body pains,nausea, vomitings,loose stools, burning micturition,cough

Not a k/c/o Dm, htn, tb, epilepsy ,cva,cad

O/E:

 Pt is c/c/c

 Temp: afebrile

Bp: 100/60mmhg

Pr:86bpm

Rr: 16cpm

Cvs: S1 s2 heard no murmurs

Rs: BAE present NVBS

P/A: soft ,non tender

CNS: NAD

Patient adviced for admission and patient is not willing to get admit

[6/8, 13:08] Krupa Kims: A 70 yrs old male with c/o Dry cough since 10 days 

Neck pain since 5 days 

No radiating 

Headache since 5 days 

Headache is diffuse not associated with blurring of vision relieved on medication

N/k/c/o HTN , DM, Asthma , TB 

O/E :- 

Pt is c/c/c 

Temp:- afebrile 

BP:- 120/80mmhg 

Pr:- 78bpm

Rr- 18cpm 

Cvs-S1S2 heard no murmurs

Rs- BAE present NVBS

P/A- soft, non tender 

CNS - NFND 

Patient is adviced for admission and patient is not willing to get admit

[6/8, 15:51] Pranati KIMS: 36 yr female with neck pain 

C/O neck pain since 1 month radiating down the left arm.

c/o tingling and numbness of medial 3&1/2 fingers of the hand.

not a clinical case of, DM, HTN, TB , asthma , epilepsy,CVA,CAD.

Pt is c/c/c

BP- 120/60mmhg

PR -76bpm

RR-18cpm

Temperature -afebrile 

CVS: s1,s2 heard ,no Murmurs

RS:BAE ,NVBS, 

P/A: soft, non tender

CNS - 

GCS- E4V5M6

TONE: RT. LT

        UL NORMAL. NORMAL 

        LL NORMAL NORMAL

POWER:

        UL 5/5. 5/5   

        LL 5/5. 5/5

REFLEXES:

        B: + +

        T: + +

        S: + +

       K: +2 +2

        A: +1 +1

        P: Flexor . Flexor

No restriction of shoulder movements 

Numbness of medial three and a half fingers on wrist extension and flexion

Carpal compression test/ durkans test positive

Diagnosis- medial nerve entrapment

Patient was adviced for admission for further evaluation but patient not willing to admit.

[6/8, 16:12] Dr. Rakesh Biswas GM: Clinical images of edema, jvp and lateral view of visceral fat with biceps?

08/06/2023

Common Groups 

Neck Pain 2

Pedal edema 2

Pain Abdomen 2

Cough 2

DAY 5- Friday ( 9/6/23)

[6/9, 09:42] +91 95506 71956: A 50 year old male pt came to opd for regular follow up k/c/o Recurrent CVA with acute infarct in right insular region? Opercular syndrome with Right acetabular fracture with k/c/o Htn since 5 years and DM 2 since 2 years .

H/o CVA 5 years ago with right hemiparesis admitted and discharged 25 days ago .Complains of drooling from mouth and complaints of inability to speak (improving) .

O/E

Pt is c/c/c

Bp- 130/80 mmHg

Temperature -Afebrile

Pr-80bpm

Rr-18cpm

Referred to Ortho OPD i/v/o previous history of RTA (Managed with skin traction and weight bearing) - still pain on walking .

[6/9, 10:00] +91 95506 71956: A 65 year old male came to OPD with chief Complaints of decreased appetite since 15 days .complains of difficulty in passing stools since 15 days , complains of dragging type of pain in both lower limbs during nights since 15 days 

H/o PTCA done 4 years back .No complains of fever and weight loss.k/c/o Asthma since 4 years and on medication (formeterol+ budesonide inhaler).

Not a k/c/o DM,Htn, thyroid disorders, epilepsy.

O/E

Pt is c/c/c

Bp- 110/80 mmHg

Temperature -Afebrile

Pr-72bpm

Rr-18cpm

Cvs- S1,S2 heard no murmurs

Rs-BAE+ NVBS Heard

P/A - Soft and nontender

Cns- HMF +.

[6/9, 10:08] Tejaswini 2k18 Kims: A 48 yr old male came to the opd with c/o headache since 1 month ( on and off) frontal region, throbbing type, not associated with photophobia, photophobia, nausea, vomiting, fever

C/o dragging sensation of neck since 1 month( on and off)

C/o dragging sensation over right lower limb since 2 months, aggravates at night. C/o blurring pf vision( far sightedness).

K/c/o htn since 1 week - on tab amlodipine 10mg po/od

 

Refered to opthal OPD I/v/o refractory error

O/E:

Bp: 100/70mm Hg

Pulse: 78bpm

Rr: 20cpm

Temp: afebrile

systemic examination:

cvs: S1 S2 heard, no mumurs

rs : bae+, NVBS

p/a: soft, non tender

CNS: nfd

[6/9, 10:19] +91 95506 71956: A 21 year old female patient came to OPD with complaints of Headache (RT.sided) throbbing type since 3 days

H/o similar episode 5 years ago and was diagnosed with ? MIGRAINE .

Similar episodes during exams

Headache is associated with nausea aggravated with stressand clusters of episodes (each episode 5-10minutes)

Not a k/c/o Htn,DM,, Asthma, thyroid disorders, epilepsy.

Diagnosis: ? Tension Headache

                  ?Migraine.

[6/9, 10:20] Dr. Rakesh Biswas GM: How does blurring of vision become far sightedness?

[6/9, 10:21] Dr. Rakesh Biswas GM: What are the details of his asthma routine disturbances since 4 years?

[6/9, 10:25] Tejaswini 2k18 Kims: He is unable to see the objects close to his eyes sir

[6/9, 10:26] Dr. Rakesh Biswas GM: That could be far sighted 

But there are many other ways to visual blurring?

[6/9, 10:29] +91 95506 71956: Pt is having breathing difficulty after waking up in the morning which relieves on taking medication weekly 2-3 times since 4 years.

[6/9, 10:33] Dr. Rakesh Biswas GM: Is he completely alright in between? Can he perform all normal activity during that time or experiences symptom induced limitations in his routine activities?

[6/9, 10:33] Tejaswini 2k18 Kims: A 60 yr old male came to the opd with c/o difficulty in breathing after walking 200mts since 1 month.

Orthopnea- no

PND - no

H/o surgery to spine 5 years ago.( H/0 accident 10 years back)

H/o chest pain on bending forward.

N/k/c/o dm, htn, cvs, cad, epilepsy, asthma

No c/o palpitations

C/o neck pain radiating to both hands.

O/E:

Patient is conscious, coherent, cooperative

Temp: afebrile

Bp: 100/60mm Hg

Pulse: 60bpm

Rr: 24cpm

[6/9, 10:34] +91 95506 71956: Yes sir ,He is alright in between,no limitation of his physical activity

[6/9, 10:34] +91 95506 71956: Routine activity**

[6/9, 10:34] Dr. Rakesh Biswas GM: Please mention the SR and JR names whom you are discussing your cases with along with their inputs about the case

[6/9, 10:47] Tejaswini 2k18 Kims: A 30 yr male came to OPD with c/o left loin pain since 1 week

C/o dribbling of urine since 1 week

Had a history of bilateral renal calculi.

Not a k/c/o htn, dm2, epilepsy, cvs, cad, thyroid disorders, asthama

O/E:

 Patient is conscious, coherent, cooperative

Temp: afebrile

Bp:100/60 mm Hg

Pulse: 70 BPM

Rr: 20cpm

Sr: Dr. Nikhitha

Jr: Dr Vivek

[6/9, 10:55] +91 95506 71956: A 25 year old male presented to OPD with c/o vomiting after eating food since 1 month.

 associated retrosternal with pain ,not associated with pain abdomen ,bowel abnormalities.

 No nausea,headache

 No episodes without having food

 No h/o wt loss.

Diagnosis: ?Chronic vomiting secondary to APD 

O/E:

Pt is c/c/c 

Bp-110/80 mmHg

Pr- 76bpm

Rr-20cpm

Temperature -Afebrile

Dr.Nikitha (SR)

Dr.Vivek (JR)

[6/9, 11:16] Tejaswini 2k18 Kims: A 33 yr old female came to the opd with c/o lower backache ( musculoskeletal pain) radiating to neck since last night.

Associated with no sleep

C/o generalized weakness since 1 week

C/o headache associated with vomiting (2-3 episodes)

No giddiness

No other joint pains

H/o vomiting with headache since 2 years. Increased on prolonged exposure to sun.

Entire night, starting at evening decreased only with medication.

O/E:

 Patient is conscious, coherent, cooperative

Bp: 120/70 mm Hg

Pr: 78bpm

Rr:18cpm

Temp: afebrile

-Tongue is dry

- thoracic vertebrae tenderness in D3-D5

- Not able to sit

- not radiating

SR: Dr. Nikhitha

JR: Dr. Vivek

[6/9, 11:23] Tejaswini 2k18 Kims: A 54 yr old female patient came to the opd with c/o tingling sensation of bilateral upper limbs since 1 month 

Nd bilateral lower limbs since 1 month

C/o neck pain since today morning.

Not a k/c/o htn, dm2, cvs, cad, thyroid disorders, epilepsy

O/E:

Patient is conscious, coherent, cooperative

Bp: 100/60mm Hg

Pulse: 84 BPM

Rr: 20cpm.

Temp : afebrile

Sr : Dr. Nikhitha

Jr: Dr. Vivek

[6/9, 11:34] +91 95506 71956: A 30 year old female came to OPD with complaints of giddiness since 2-3 months , increased from 4 days , associated with sweating, palpitations,nausea.

1 episode of syncope .

More in the dark , and on bending for rangoli .

Occasional headache is present rotational ,more towards right.

O/E:

Pt is c/c/c 

Bp- 100/70 mmHg

Pr- 90 bpm

Rr-19cpm

Temperature -Afebrile

No pallor

Romberg test- Mild sway present

Cerebellum -tandem Walk- Normal'

Dysdiadochokinesia - Normal 

Finger nose coordination - able to perform well

Diagnosis:

Vertigenous migraine with Aura -Auditory,visual ,+dark spots .

SR-Dr.Nikitha

JR-Dr.Vivek (PGY1)

[6/9, 11:36] Tejaswini 2k18 Kims: A 32 yr old male came to OPD with c/o diffuse chest pain since yesterday for 5-10min relieved with antacids, following consumption of tamarind.

Not associated with vomitings.

O/E:

Patient is conscious, coherent, cooperative

Bp: 120/90 mm Hg

Pr: 84bpm

Rr: 18cpm

Temp: Afebrile

Diagnosis:

Young onset denovo HTN Essential?

Sr: Dr.Nikhitha

Jr: Dr. Vivek

[6/9, 11:45] Tejaswini 2k18 Kims: A 62 yr old female with c/o sob on walking for long distance( compared to previous fitnes) occasionally since 6 months.

Unintentional weight gain since 2 months.

K/c/o dm2 since 2 years on tab metformin 500mg po/od

N/k/c/o htn, thyroid disorders, asthma, epilepsy

O/E:

 Patient is conscious, coherent, cooperative

Temp: Afebrile

Bp:110/70 mmHg

Pr: 70bpm

Rr: 26 cpm

Sr: Dr. Nikhitha

Jr: Dr. Vivek(PGY1)

[6/9, 11:52] Tejaswini 2k18 Kims: A 37 yr old female with c/o headache radiating from vertex to neck since 15 days , daily , increased on exposure to sun for 2-3 hrs

Not releived on medication since 2-3 days

No nausea , vomiting, photophobia

Regular menses: 5/30

O/E:

Patient is conscious, coherent cooperative

Bp: 90/60 mm Hg

Pr: 96 BPM

Rr: 20 cpm

Temp: afebrile 

Pallor +

Right paraspinal tenderness +

Diagnosis: 

Headache, migraine without aura

Sr: Dr. Nikhitha

Jr: Dr. Vivek ( PGY1)

[6/9, 11:53] +91 95506 71956: A 65 year old female patient came to OPD with c/o chest pain (left sided)since 2 months 

C/o Sob since 2 months 

C/0 fever on&off low grade since 2 months 

K/c/o Pulmonary Kochs since 2 months onATT

Not a k/c/o Dm,Htn,CVA,asthma, epilepsy, thyroid disorders .

O/E

Pt is c/c/c 

Bp- 100/50 mm Hg

Pr-80bpm

Rr-20 cpm

Temperature -Afebrile 

Cvs-S1 s2 heard

Palpable P2+

Parasternal heave +

Rs:Bae+

 B/l Basal crepts +.

Dr.Nikitha (SR)

Dr.Vivek (JR)

[6/9, 12:13] +91 95506 71956: A 47 year old male patient came to OPD for regular check up k/c/o Type 2 DM,Htn since 10 years .

N/C/o Polyphagia,polydypsia,polyuria.

N/H/O tingling /loss of sensation 

N/H/o fever ,burning micturition .

Pt is on regular medication for DM -Glimi M1,for Htn- Amlodipine-1/2 tab ,Telma 20 

N/k/c/o CAD, thyroid disorders, epilepsy,tb.

O/E

Pt is c/c/c

Bp-100/60 mmHg

Pr-66bpm

Rr-20 cpm

Temperature -afebrile

Cvs- S1 S2 heard no murmurs

Rs-BAE+

NVBS heard.

Cns-Nfd

Dr.Nikitha (SR)

Dr.Vivek (JR)

[6/9, 12:15] Tejaswini 2k18 Kims: A 38 yr old male patient came to the opd with c/o low grade fever more during night since 1 month.

No weight loss

No arthralgia

H/o Htn since 6 months on prolomet xl 12.5 mg medication

H/o Jaundice 6 months back with thrombocytopenia - releived conservatively

Previous report in April shows: 

CUE- pus cells loaded

        Albumin +4

--- AKI

O/E :

Patient is conscious, coherent cooperative 

Bp: 110/80 mm Hg

Pr: 84 BPM

Rr: 74 cpm

No pallor , icterus, cyanosis, clubbing, lymphadenopathy

Tremors +

Systemic examination:

Cvs: S1 S2 heard, No murmurs

P/a : soft , non tender

CNS: nfd

Rr: blae+, NVBS

Sr: Dr. Nikhitha

Jr: Dr. Vivek ( PGY1)

[6/9, 12:26] +91 95506 71956: A 65 year old male patient came to OPD with c/o fever since 1 month low grade not associated with chills,fever is intermittent more during night 

C/o throat pain since 1 month associated with difficulty in swallowing more to solids since 1 month 

K/c/o Htn,and Type 2 DM since 2 years on regular medication on Tab.Glimi M1 ,Tab.Atenolol 25 mg.

C/o pain in Lt.LL since 1 week.

Difficulty in getting up from squatting position .

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 120/70 mmHg

Pr-68bpm

Rr-19cpm

Cvs-S1.s2 heard

Rs - BAE+

Cns-Nfd

Dr.Nikitha (SR)

Dr.Vivek (JR)

[6/9, 12:32] Tejaswini 2k18 Kims: A 47 yr male patient came to the opd with c/o bilateral pedal edema since 3 months.

No history of fever, nausea, vomiting, pain, burning micturition .

K/c/o dm since 6 years and on tab metformin and glimipiride

N/k/c/o htn, epilepsy, asthma, cvs,cad , thyroid disorders

 

L/E:

Patient is conscious, coherent, cooperative

No local rise of temperature of bilateral lower limbs.

No tenderness

Bilateral pedal edema present

Pitting type

Bp : 120/70 mm Hg

Rr: 18cpm

Pr: 80bpm

Systemic examination:

Cvs : S1 S2 heard, No murmurs

CNS: nfd

RS: blae+, NVBS

P/a: soft, nontender

Sr: Dr Nikhitha

Jr: Dr. Vivek( PGY1)

[6/9, 12:32] +91 95506 71956: A 60 year old female patient came to OPD with c/o chest pain since 1 month on& off diffuse type,and .

 discomfort .

 C/o regurgitation since 1 month 

 No h/o pain abdomen, vomiting,loose stools .

 Not a k/c/o Dm,Htn,Cad,CVA, thyroid disorder , epilepsy .

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 120/70 mmHg

Pr-70bpm

Rr-20cpm

Cvs-S1.s2 heard

Rs - BAE+

Cns-Nfd

Dr.Nikitha (SR)

Dr.Vivek (JR)

[6/9, 12:38] Tejaswini 2k18 Kims: A 60 yr old male came to the opd with c/o sob( grade 3) since 20 days.

C/0 cough ( productive) since 15 days 

H/o fever 10 days ago for 2 days relieved on medication.

H/o wheeze present since 10 days

N/k/c/o htn, dm, cad, cvs, thyroid disorders, epilepsy, asthma

Sr: Dr. Nikhitha

Jr: Dr. Vivek

O/E:

 Patient is conscious, coherent, cooperative

Bp: 100/70 mmHg

Pulse : 90bpm

Rr: 18 cpm

Temp: afebrile

Common groups ( 09/6/23)

Headache -4

Chestpain -4 

SOB - 2

Fever - 2

Neck pain 2

Day 6 - Saturday ( 10/6/23)

[6/10, 10:06] Vishnu Rohit KIMS: A 20 yera old female came to OPD with

C/o stiffness of both the hands since 3 months(increased in morning and relieved after some time )

Irregular menstruation +(6/30 since 5 years)

Loss of appetite +

Weight gain +

k/c/o asthma since 3 years on regular medication(on formeterol fumerate and budesonide 400mcg acute episode )

K/c/o hypothyroidism since 2 years (on medication thyronorm)

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 120/70 mmHg

Pr-70bpm

Rr-20cpm

Cvs-S1.s2 heard

Rs - BAE+

Cns-Nfd

L/e

Involvement of DIP,PIP,WRIST JOINT,SHOULDER JOINT,ELBOW JOINT KNEE JOINT,ANKLE JOINT 7 JOINTS INVOLVED

tenderness + over DIP,PIP restriction of movements+

No deformity 

Dr.Nikitha (SR)

Dr.harika (JR)

PATIENT WAS ADVISED ADMISSION BUT NOT WILLING TO GET ADMITTED

[6/10, 10:17] Vishnu Rohit KIMS: A 45 year old male patient came to OPD with c/o constipation since 10 days,passing stools once in 3-4 days

Pain during defecation +

No c/o sob,chestpain,palpitation 

 No c/o pain abdomen,vomitings

K/c/o DM2 since 22 years(on medication inj.biphasic insulin 13u-12u),HTN since 20 years(on medication T.clinidipine)

 Not a k/c/o Cad,CVA, thyroid disorder , epilepsy .

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 120/70 mmHg

Pr-70bpm

Rr-20cpm

Cvs-S1.s2 heard

Rs - BAE+

Cns-Nfd

P/a-soft,no tender,Bowel sounds +

Treatment:

Diet modification (asked to eat more fibre diet )

Dr.Nikitha (SR)

Dr.Harika (JR)

Patient was advised admission but not willing to get admitted

[6/10, 10:52] Vishnu Rohit KIMS: A 57 year old male patient came to OPD with c/o headache and neck pain radiating to occipital area,dragging type of pain

Duration-1 month,intermittently once every 3-4 days relieved with rest

h/o consumption of pesticide 1 month back(?op poisoning) and was treated conservatively at local hospital

H/o renal calculi operated 1yr back

 Not a k/c/o Dm,Htn,Cad,CVA, thyroid disorder , epilepsy .

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 100/80 mmHg

Pr-80bpm

Rr-20cpm

Cvs-S1.s2 heard

Rs - BAE+

Cns-Nfd

Cervical spine-

no paraspinal stiffness

C-spine-normal

Rom-normal

Rhombergs-negative

Nystagmus-nehative

Dysdiadokinesia-negative 

Dr.Nikitha (SR)

Dr.deepika (JR)

Patient was advised admission but not willing to get admitted

[6/10, 10:54] Vishnu Rohit KIMS: A 36 year old male patient came with c/o giddiness,chest pain, 

Retrosternal cough with intermittent sputum

Pt has h/o pesticide consumption along with alcohol followed by hospitalization outside. Gastric lavage done and 

connected to mv for 4 days and left on LAMA after excubation. 

Chronic alcoholic since 20 yrs

O/E

Pt is c/c/c 

Mild icterus 

No tremors

No pallor and tachypnoea

R.S- wheeze + end expiratory in 

left Infraclavicular and Mammary 

Temperature -afebrile

Bp- 170/120 mmHg

PR-74bpm

RR-20cpm

Cvs-S1.s2 heard

No parasternal heave 

Dr.Nikitha (SR)

Dr.Harika (JR)

Patient was advised admission but not willing to get admitted

[6/10, 10:56] Vishnu Rohit KIMS: A 45 year old female patient came with c/o heartburn since 5 days and pain over lt iliac fossa since 2 days non radiating 

No chest pain and palpitations 

No fever vomitings and diarrhoea 

No pedal oedema 

Not a k/c/o DM,HTN,TB,ASTHMA,thyroid disorders 

O/E

Pt is c/c/c 

Pallor +

R.S- BAE+, NVBS

Temperature -afebrile

Bp- 130/80 mmHg

PR-80bpm

RR-18cpm

Cvs-S1.s2 heard

No parasternal heave 

P/A- soft and tenderness + in lt iliac fossa 

No guarding and rigidity 

Dr.Harika (PGY1)

Patient was advised admission but not willing to get admitted

[6/10, 11:05] Vishnu Rohit KIMS: A 45 year old Female patient came to OPD with c/o swelling of both hands,legs and also bloating tof abdomen since 10 days

C/0 lower abdominal pain since 10 days

Pain in the left shoulder and arm since 1 month

C/0 sob since 1month

Orthopnea +,pnd-

Decreased frequency of urination + since 1 month

No burning micturition 

 Not a k/c/o Dm,Htn,Cad,CVA, thyroid disorder , epilepsy .

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 110/80 mmHg

Pr-80bpm

Rr-20cpm

Pallor-ve

Pedal edema +(grade 2 putting type)

Cvs-S1.s2 heard,no jvp raised 

Rs - BAE+,nvbs heard

Cns-Nfd

P/A-soft,non tender,bowel sounds present,distended,obese

 

Dr.deepika (PGY2)

Patient was advised admission but not willing to get admitted

[6/10, 11:13] Vishnu Rohit KIMS: A 13 year old Female patient came to OPD with c/o fever since 2 days,cold since 2 days,throat pain since 2days.

Morning raise of temperature 

No burning micturition 

Headache +(temporal region)

H/o dengue 1 year back(got admitted for low platelet count and was treated)

 N/K/C/O Dm,Htn,Cad,CVA, thyroid disorder , epilepsy .

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 110/80 mmHg

Pr-80bpm

Rr-20cpm

Cvs-S1.s2 heard,Tachycardia

Rs - BAE+,nvbs heard

Cns-Nfd

P/A-soft,non tender,bowel sounds present.

 Diagnosis-URTI

Dr.deepika (PGY2)

Patient was advised admission but not willing to get admitted

[6/10, 11:45] Vishnu Rohit KIMS: A 36 year old Female patient came to OPD with

K/c/o DM since 1 year(on HAI 16U-16U-16U) came for follow up,was admitted for DKA with b/l LL. CELLULITIS 1 week back 

Lower limb swelling decreased 

Fever -ve

Tingling and numbness + uL and LL

Burning micturition +

Polyuria-,polyphagia-,polydypsia-

 N/K/C/O Htn,Cad,CVA, thyroid disorder , epilepsy .

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 110/80 mmHg

Pr-80bpm

Rr-20cpm

Cvs-S1.s2+,jvp not raised heard.

Rs - BAE+,nvbs heard

Cns-Nfd

P/A-soft,non tender,bowel sounds present.

Lower limb examination-

Peripheral pulses +

Skin discoloration +

Pitting type pedal edema+ (Grade-2)

No active oozing

No local raise of temperature 

Healing ulceration + at dorsum of left foot

Dr.deepika (PGY2)

Patient was advised admission but not willing to get admitted

[6/10, 11:59] +91 91338 80836: A 50 year old male patient came with c/o involuntary movements of both upper limbs and head which progressed from left arm to right arm since 3 years

He is a farmer,able to do farm work,but has difficulty in holding a glass of water or eating

 Movements are present at rest,absent during sleep and increase on trying to reach objects or work, 

Decreased in intensity when he stops drink for that day

Chronic alcoholic ,everyday consumption

Pt had history of fall from tree and sustained fracture of ?coccyx and sacrum and walking with limp without support since then

O/E

Pt is c/c/c 

Speech- normal

Memory- intact 

Titubations +

Movements: high frequency, low amplitude (tremors)

Present at rest, increased on trying to reach object (terminal part)

Cerebellum:

Able to perform tandem walking with mild swaying 

Gait- base:normal,

Waddle of left hip.

Stance,stride,turn:normal

No Dysdiadokinesia 

No Finger nose incoordination 

No rigidity 

Nystagmus:absent

Bp- 100/60 mmHg

PR-72bpm

RR-18cpm

Cvs-S1.s2 heard

Dr.Nikitha (SR)

Patient was advised admission but not willing to get admitted as he came with his wife who will be unable to tend to him here.

Will come back with other family members

[6/10, 12:25] +91 91338 80836: A 55 year old male patient came with c/o chest pain [lt>rt] 

Non radiating and more pain during inspiration 

No c/o palpitations, SOB, orthopnoea, PND

No fever, loose stools, burning micturition, pedal oedema 

No costochondral junction tenderness. 

O/E

Pt is c/c/c  

Bp- 110/80 mmHg

PR-82bpm

RR-17cpm

Cvs-S1.s2 heard

RS-BAE+, NVBS

Dr.Harika (PGY1)

Patient was advised admission but not willing to get admitted

[6/10, 12:27] +91 91338 80836: A 32 year old female patient came with c/o burning sensation(retrosternal) since 10days

No belching 

H/o similar episodes 1yr back for 10days 

K/c/o hypothyroidism since 3 yrs for which she is using tab thyronorm 150mcg 

Menstrual history -normal 

Last TFT- 

TSH: 32.75uIU/mL

O/E

Pt is c/c/c  

No pallor

No pedal oedema 

Goitre +, diffuse, no nodules

Bp- 90/60 mmHg

PR-75bpm

RR-18cpm

Cvs-S1.s2 heard

RS-BAE+, NVBS

Diagnosis- APD with primary hypothyroidism 

Dr.Nikitha(SR)

Patient was advised admission but not willing to get admitted

[6/10, 12:31] +91 91338 80836: A 50 Yr old female came with 

c/o pain in joints involving DIP,PIP, wrist joint and shoulder joint, elbow knee and ankle joint 

O/E- 

Synovial thickening of DIP and PIP 

No tenderness and restriction of movements 

Erosions positive of carpal bone(hamate) of rt hand and

B/L DIP 2nd and 4th finger

Bp-110/80mm hg

PR- 60bpm

RR- 17cpm

RS- BAE +

CVS- S1 S2 heard 

Dr.Harika(PGY1)

Patient was advised admission but not willing to get admitted

[6/10, 12:33] Vishnu Rohit KIMS: A 40 year old female patient came to OPD with c/o  

Headache at vertex and occipital region since 1 year

Pricking and dragging type of pain associated with radiation to neck

H/o old lacunar infarct at right lentiform nucleus 

K/c/o cervical spondylosis under conservative management 

Frequency-weekly once 

Duration 4-5 hours

Increased while bending farward/sun expoaure 

Associated with nausea + vomiting +(non projectile)

Throbbing type,photophobia+,phonophobia +

 Not a k/c/o Dm,Htn,Cad,CVA, thyroid disorder , epilepsy .

Diagnosis-migraine with c-spondylosis with old cva

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 130/80 mmHg

Pr-84bpm

Rr-20cpm

Cvs-S1.s2 heard

Rs - BAE+

Cns-Nfd

Cervical spine-

Rom-normal

Dr.deepika (PGY2)

Patient was advised admission but not willing to get admitted

[6/10, 12:41] +91 91338 80836: A 36 Yr old female came with complaints of lt sided chest pain since 1 Yr, non radiating 

C/o SOB, grade 2-3 since 6 months.

Insidious in onset and gradually progressive 

No orthopnea and PND

C/o constipation 

No c/o fever, loose stools, vomitings, cough and burning micturition 

Not a k/c/o DM, HTN,TB,thyroid disorders, etc 

O/E

Pt is c/c/c  

Mild pallor

No oedema 

Bp- 120/70mmHg

PR-96bpm

RR-24cpm

Cvs-S1.s2 heard

RS-BAE+, NVBS

6 min walk test- 

Before

Bp- 120/70

PR-96bpm

Spo2- 97% 

RR-24

After-

Bp-130/80

PR-94

Rr-27

Spo2-97

Dr.Harika(PGY1)

Patient was advised admission but not willing to get admitted

[6/10, 12:43] Vishnu Rohit KIMS: A 36 year old male patient came to OPD with c/o  

 Fever since 1 day, high grade,continuous associated with chills and rigors relieved with medication a/w cough cold,burning micturition

Pain abdomen-

Generalised body pains+

Retro orbital pain+

Cough since 1 day,productive 

Sputum-scanty,mucoid,whitish yellow,-veblood tinged

No sob,chest pain,loose stools,vomiting,bleedinganifestations

 Not a k/c/o Dm,Htn,Cad,CVA, thyroid disorder , epilepsy .

Diagnosis-?URTI?VIRAL PYREXIA

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 110/80 mmHg

Pr-84bpm

Rr-20cpm

Cvs-S1.s2 heard,NO RAISED JVP

Rs - BAE+

Cns-Nfd

SUPINE -BP-120/70,PR-88BPM

STANDING-BP-110/80,PR-110BPM

Dr.deepika (PGY2)

Patient was advised admission but not willing to get admitted

[6/10, 12:55] +91 91338 80836: A 49 Yr old male came with 

c/o burning micturition since 1 Yr, on and off.

Relieved with medication temporarily but not completely

No urgency, frequency, hesitancy

No fever 

C/o generalised weakness since 6 months

No giddiness

O/E- 

 No erosions / papules seen over penis, genital region

Hypopigmented lesion present over shaft and bulb of penis since childhood 

Bp-110/60mm hg

PR- 84bpm

RR- 17cpm

RS- BAE +

CVS- S1 S2 heard 

Dr.Harika(PGY1)

Patient was advised admission but not willing to get admitted

[6/10, 14:51] Vishnu Rohit KIMS: A 37 year old female came to OPD with c/o b/l lower limb pain

C/o upper limb wrist and finger swelling since 6 months a/w morning stiffness for 30 min relieved while walking 

C/o inability in walking/standing from supine position not a/w pain.

No involvement of elbow and shoulder.

Pain at left knee and lower back radiating to calf

K/c/o lumbar spondylosis

 Not a k/c/o Dm,Htn,Cad,CVA, thyroid disorder , epilepsy .

O/E

Pt is c/c/c 

Temperature -afebrile

Bp- 110/80 mmHg

Pr-84bpm

Rr-20cpm

Cvs-S1.s2 heard.

Rs - BAE+

Cns-Nfd

JOINTS-

UL-Swelling +,PIP,DIP

No local raise of temperature

No ROM/deformity at PIP,DIP,WRIST

synovial thickness + at mcp joint (b/l)

Elbow,shoulder ROM normal

Spine- disc spaces normal

SLRT-POSITIVE AT 60 DEGREE LEFT

no paraspinal stiffness 

 

Dr.deepika (PGY2)

Patient was advised admission but not willing to get admitted

[6/10, 16:11] Dr. Rakesh Biswas GM: @stats, @⁨+91 93985 87059⁩ how many seen and how many taken in 

@⁨Muskaan⁩ Break up of the types cases in numbers?

[6/10, 17:06] Muskaan: Will update in a while sir..on it

Common group ( 10/6/23)

Headache - 2

Chestpain - 3

Heartburn - 3

Fever - 2

Joint pains -- 2

Swelling UL and LL - 2