PLA BOOK PROJECT DRAFT OPD week-5

 Week-5


22 May 2022,Monday

[22/05/23, 9:45:54 AM] ~ Prathyusha Singam: 1
Op. No. 20210318003

A 40year old male who is a tractor driver by occupation came with 
C/o pedal edema (pitting type) since 1week, insidious in onset,  aggravated on prolonged sitting, relieved on walking and limb elevation, presently mainly by the evening. 
No C/o SOB, chest pain and decreased urine output. 
K/c/o HTN since 3years. On T. Telma 40mg PO/OD. 
K/c/o hypercholesterolemia and is on medication. 
N/k/c/o DM, TB, CVA, CAD. 
Vitals:
Pt is c/c/c
BP: 130/80 mm Hg
PR: 82bpm
RR: 19cpm
Temp: 98.7 F
CVS: S1, S2 heard. No murmurs.
RS: BAE+, NVBS heard.
P/A : soft, NT, no organomegaly. 
CNS:NFND
Advised: walking for 10mins for every 2hours and limb elevation 
Patient is not willing for admission as he is working today.

[22/05/23, 9:46:57 AM] Rakesh Biswas Sir: Clinical images of visceral fat and biceps lateral view asap

[22/05/23, 9:48:05 AM] Rakesh Biswas Sir: Familial hypercholesterolemia? 

@917780285086 Is anti cholesterol drugs indicated for primary prevention of polygenic hypercholesterolemia?

[22/05/23, 9:53:50 AM] ~ vamsi Krishna: SL NO 2

OP NO: 20230534797 
42 year old female

C/o giddiness since 3 days
2 to 3 times per day since 3 days
Spinning sensation of head mainly while (neck extension) rising the head above. Sitting sleeping position
No buzzing sensation in ear ear pain 
Diplopia (+)
Not associated while walking or standing
No clo neck pain head ache nausea
H/o similar complaints 3 years ago subsided after using medication

N/k/c/o HTN,,thyroid,epilepsy,cad,cva

O/E:  
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt
No dysdiadokinesia
No fingers incordination
Rombergs test -no swaying
No nystagmus


Patient is advised for admission she will come back on wednesday

[22/05/23, 9:54:28 AM] ~ Dr.Sai Pavan👨‍⚕️: 5.op no :20210424391
A  30 year old female accountant by  occupation ( goes to work at  9 am ,lunch at 1 pm at work and reaches home by  5 pm and continues his works at home ,dinner at 8 pm and goes to bed by 9 pm)
Came with c/o fever since 2 months not associated with chills, intermittent,evening rise of temperature present , associated with generalised body pains ,headache and cold 
No c/o burning micturition,pain abdomen, vomitings and loose stools 
Not a k/c/o HTN,DM ,CVA,cad,tb,asthma
On examination:
Bp:120/80 mm hg 
PR:78 bpm
RR:18 cpm
Cvs:s1 s2 + ,no murmurs
Rs: BAE+ ,no added sounds
P/A:soft;  non tender
CNS: NFND

[22/05/23, 10:08:45 AM] ~ Dr.Sai Pavan👨‍⚕️: 6.op no :20210406079
A  45 year old male  driver by  occupation ( goes to work at  8 am ,lunch at 1 pm at work and reaches home by   7 pm and continues his works at home ,dinner at 9 pm and goes to bed by 10 pm)
Came with c/o right  chest pain since 4 days,diffuse ,non radiating ,intermittent,no local tenderness,not associated with sweating, palpitations,sob,syncopal attacks 
Pain increased on exertion and relieved on taking rest 
K/c/o diabetes since 1 year and on tab.metformin 500 mg OD
Not a k/c/o HTN,DM ,CVA,cad,tb,asthma
On examination:
Bp:100/80 mm hg 
PR:86 bpm
RR:18 cpm
Cvs:s1 s2 + ,no murmurs
Rs: BAE+ ,no added sounds
P/A:soft;  non tender
CNS: NFND

[22/05/23, 10:14:06 AM] Rakesh Biswas Sir: Please don't waste our reading time by writing 'so much of useless negative history!! 

Please tell us how her routine changed after she developed fever since two months from that before two months

[22/05/23, 10:14:59 AM] Rakesh Biswas Sir: Advise admission 

What about his routine change since last 4 days?

[22/05/23, 10:28:46 AM] ~ vamsi Krishna: SL NO 4

OP NO: 20210219288

67M
C/o cough since 15 days 
On and off cough since 1 year
Change in quality of cough dry to wet cough
Mucoid sputum mainly during night time 
H/o similar complaints 1 year ago relieved on medication 
C/o inguinal hernia ( noticed since 1mnth)

N/k/c/o HTN,,thyroid,epilepsy,cad,cva

O/E:  
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt

Diagnosis- chronic cough  with acute exacerbation with ? Right inguinal hernia

Patient is advised for admission he will come back after 1 week

[22/05/23, 10:34:21 AM] Rakesh Biswas Sir: Change of routine from one year back and after development of the cough?

[22/05/23, 10:36:09 AM] Rakesh Biswas Sir:  Hope you are logging all the inputs including mine here?👇

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

Currently it appears to be falling on deaf ears or am I being biased?

[22/05/23, 10:50:52 AM] ~ Prathyusha Singam: 12
Op. No 20230535315

A 46year old male came with c/o bloating sensation since 6months, aggravated since 3 days and on intake of spicy food. 
C/o low backache since 3days, aggravated on bending down. 
C/o hard stools. Staining of stools +, passing stools regularly. 
N/k/c/o HTN, DM, TB, CVA, CAD. 
O/E: spinal tenderness+, SLRT - negative
Vitals:
Pt is c/c/c
BP: 130/90 mm Hg
PR: 86bpm
RR: 20cpm
Temp: 98.4 F
CVS: S1, S2 heard. No murmurs.
RS: BAE+, NVBS heard.
P/A : soft, NT, no organomegaly. 
CNS:NFND
Provisional Diagnosis: Acid peptic disease
Advised: 
 Intake of plenty of oral fluids 
 Completely avoid spicy and oily food
 Explained about high fibre diet. 
 Patient is advised admission and is willing to come after 3days.

[22/05/23, 11:04:26 AM] Manogyna: Yes sir

[22/05/23, 11:05:08 AM] ~ Prathyusha Singam: 9
Op. No. 20230535188

A 40year old female came with c/o lower abdominal pain since 2-3months, intermittent, dragging type of pain, present during micturition associated with low grade fever. 
C/o epigastric pain since 20days, intermittent, stabbing type of pain. 
C/o SOB (grade -III MMRC), orthopnea, profuse sweating since 1month. 
K/c/o DM -II since 6years. 
N/k/c/o HTN, TB, CVA, CAD. 
Vitals:
Pt is c/c/c
BP: 110/80 mm Hg
PR: 86bpm
RR: 20cpm
Temp: 98.4 F
CVS: S1, S2 heard. No murmurs.
RS: BAE+, NVBS heard.
P/A : soft, NT, no organomegaly. 
CNS:NFND

Provisional Diagnosis: ?UTI
 Patient is getting admitted

[22/05/23, 11:27:24 AM] ~ Prathyusha Singam: 13
Op. No. 20210217724

A 34year old female who is a housewife came with c/o tingling sensation in upper and lower limbs since 3-4months mainlyin soles upto knees and palms upto elbows. 
C/o pain in right upper and lower limb with tingling sensation of right side of mouth since yesterday. 
CT brain was done yesterday, report showed no abnormality. 
O/E of upper and lower limbs: (L3-S1, C5-C8)
Sensory examination - normal 
Fine touch - normal 
Hb -7.4(done in last month)
Dietary history includes low protein diet. (eats Egg,dal, non veg only once in a week)
N/k/c/o HTN, DM, TB, CVA, CAD
Vitals:
Pt is c/c/c
BP: 110/80 mm Hg
PR: 76bpm
RR: 20cpm
Temp: 98 F
CVS: S1, S2 heard. No murmurs.
RS: BAE+, NVBS heard.
P/A : soft, NT, no organomegaly. 
CNS:NFND
Provisional diagnosis: Right sided paraesthesia with right sided tingling ?likely stress related
Advice:
Iron rich diet
Well balanced diet

[22/05/23, 11:42:27 AM] ~ vamsi Krishna: SL NO 10

OP NO: 20230535214

60F
C/o low backache since 5 to days radiating to left lower limb
Neck pain since 1 week with head ache associated with giddiness / tingling sensation of upperlimbs bilateral 


k/c/o HTN since  3 years ,
n/k/c/o thyroid,epilepsy,cad,cva
H/o trauma to head due to slip and fall 
IC bleed  left hemiplegia since 2years
H/o lumbar and cervical spondylosis 1 year back

O/E:  
Cvs- s1s2 heard
RS - BAE + , NVBS heard
P/A - soft,nt
CNS HMF intact 
Pupils b/l nsrl
Cranial nerves intact
Motor system normal 
Tone  normal 
Power  ul.       Ll
    Rt    4/5    4/5
    Lt    3/5    2/5
Reflexes 
        B   T    S    K   A  Plantar

Rt.   -      -     -     -     -     flxn
Lt   +3  +3 +3  +3  +2.  Extsn

Advice 
Physiotherapy of left upper and lower limb

Patient is advised for admission but not willing.

[22/05/23, 11:53:38 AM] ~ Prathyusha Singam: 18
Op. No. 20230535393

A 38year old male came with c/o tingling sensation in right arm lasting for 2-3mins. Increased on feeling tensed, 4-5times/day. 
Precipitated by loud sounds, stress, associated with intermittent palpitations, sweating, giddiness. 
No SOB
O/E:
No tachypnea 
Restriction of right shoulder adduction, extension 
N/k/c/o HTN, DM, TB, CVA, CAD
Vitals:
Pt is c/c/c
BP: 100/60 mm Hg
PR: 80bpm
RR: 20cpm
Temp: 98.1F
CVS: S1, S2 heard. No murmurs.
RS: BAE+, NVBS heard.
P/A : soft, NT, no organomegaly. 
CNS:NFND
Advised : Psychiatry referral I/v/o anxiety

[22/05/23, 12:00:52 PM] ~ Dr.Sai Pavan👨‍⚕️: 21.op no :20210535840
A  45 year old female Came with c/o headache and neck pain since 2 months associated with  right upper limb pain
B/l shoulder joint pain since 2 months 
B/l knee pains since 2 months 
No early morning stiffness
Left sided chest pain  since 20 days not associated with sweating , palpitations,sob ,syncopal attacks.
Not a k/c/o HTN,DM ,CVA,cad,tb,asthma
On examination:
Bp:130/80 mm hg 
PR:86 bpm
RR:18 cpm
Cvs:s1 s2 + ,no murmurs
Rs: BAE+ ,no added sounds
P/A:soft;  non tender
CNS: NFND
Patient advised admission but not willing

[22/05/23, 12:14:01 PM] ~ Dr.Sai Pavan👨‍⚕️: 23.op no :20230535394
A  70  year old male Came with c/o b/l pedal edema since 10 days pitting type till knees,used medication but not relieved associated with decreased urine output
Constipation since 2 -3 months ,passed hard stools
 k/c/o HTN since 2 years and on medication 
On examination:
Bp:130/80 mm hg 
PR:82 bpm
RR:16 cpm
Cvs:s1 s2 + ,no murmurs
Rs: BAE+ ,no added sounds
P/A:soft;  non tender
CNS: NFND
Patient advised admission but not willing

[22/05/23, 12:25:40 PM] ~ vamsi Krishna: SL NO 23

OP NO: 20230535402

45 M
C/o pain abdomen in epigastric region (burning typee) since 2 years  associated with heart burn

Abdominal bloating sensation after taking food 

Indigestion (+)
Palpitations (+)
No h/o chest pain /sob / syncopial attack 
K/c/o HTN. Since 2years
N/k/c/o thyroid,epilepsy,cad,cva

O/E:  
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt

Patient is advised for admission but not willing.

[22/05/23, 12:35:00 PM] ~ Dr.Sai Pavan👨‍⚕️: 32.op no :20230535881
A  50  year old female Came with c/o b/l pedal edema since 10 days pitting type till mid calf ,low back ache non radiating since 15 days associated with tingling sensation in b/l lower limbs 
K/c/o HTN since 6 yrs and on medication ( unknown).
On examination:
Bp:140/80 mm hg 
PR:80bpm
RR:16 cpm
Cvs:s1 s2 + ,no murmurs
Rs: BAE+ ,no added sounds
P/A:soft;  non tender
CNS: NFND
Patient advised admission but not willing

[22/05/23, 2:36:10 PM] Rakesh Biswas Sir: What kind of history is 

H/o lifting weights!! 

H/o bending neck and walking 

The history needs to flow in continuity and not in a fragmented manner as presented above!!

[22/05/23, 2:38:03 PM] ~ Prathyusha Singam: Ok sir.

[22/05/23, 2:38:49 PM] Rakesh Biswas Sir: What about the history of the two patients of diabetes we saw in the opd ?

One getting admitted with basal ganglia involvement 

Another with Diabetes getting admitted due to some other reason who's relative was blind. 

Why are we not sharing all the patients?

[22/05/23, 2:43:30 PM] ~ Prathyusha Singam: This is the patient who's relative was blind sir.

[22/05/23, 2:51:11 PM] Rakesh Biswas Sir: Alright. What about the Hemiballismus and hemichorea patient?

[22/05/23, 3:08:51 PM] ~ vamsi Krishna: SL NO 42

OP NO: 20230598994

35F
Headache since 6months
Pricking type headache,continuous type
Not relieved on medication neckpain (+)

N/k/c/o HTN,,thyroid,epilepsy,cad,cva

O/E:  
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt

Diagnosis - tension headache

Advised for admission but patient is not willing as she has to go for work

[22/05/23, 4:13:44 PM] Rakesh Biswas Sir: From 32 we jumped to 42!!

What about the others? 

How many total patients seen and how many admitted?
[22/05/23, 5:16:21 PM] Lohith Pg Gm : 5 admissions from OP sir

[22/05/23, 8:17:23 PM] Rakesh Biswas Sir: And seen 42?

[22/05/23, 8:22:50 PM] Lohith Pg Gm : No sir, around 35 cases were seen

[22/05/23, 8:33:42 PM] Rakesh Biswas Sir: 👆






23rd May 2023,Tuesday

[23/05/23, 10:21:03 AM] ~ Basani Sravanthi: No.1 
Op :20230536999
20 F came to opd with  C/o difficulty in breathing from today morning,acute,lasted for 5 mins,a/w headache.
No h/o chest pain , palpitations.
No H/o fever,cough,cold ,nausea,vomiting.
Past history:
H/o similar complaints in the past 20 days bac, relieved on taking rest.
N/k/o htn,dm,thyroid,epilepsy,tb
Personal history: patient is allergic to dust to cold weather
Family history:not significant
VITALS:
BP: 120/80mm hg
Pr : 78bpm
Rr: 16 cpm
No pallor,icterus,cyanosis,clubbing,lymphadenopathy,edema
Patient is/c/c
R.s:bae+,nvbs
Cns:nfnd
Cvs:s1s2heard,no murmers
P/a:soft,non tender
Patient is advised for admission but not willing for admission

[23/05/23, 10:22:51 AM] Rakesh Biswas Sir:Need your team help to prepare their case reports and PaJR groups asap after obtaining their signed informed consents

[23/05/23, 10:41:21 AM] ~ Nikithchandra: 2
Op. No. 20230406375

A 38year old female who is a housewife came with 

c/o pedal edema since 1week,on and off,non pitting type, insidious in onset,non progressive,decresed on sitting and increased on walking

No history of burning micturition,no history of decreased Urine output,no h/o chest pain, difficult in breathing

Past h/o known case of tinea corporis and tinea cruris on medication since 45days
 Known case of htnsince 10years on medication tab.SARTEL AM

N/k/c/o, DM, TB, CVA, CAD
Vitals:
Pt is c/c/c
pedal edema:upto ankle,non pitting type
No pallor,icterus,cyanosis,clubbing,lymphadenopathy
BP: 120/80 mm Hg
PR: 88bpm
RR: 20cpm
CVS: S1, S2 heard. No murmurs.
RS: BAE+, NVBS heard.
P/A : soft, NT, no organomegaly. 
CNS:NFND

Patient is advised for admission but not willing

[23/05/23, 11:28:15 AM] ~ Basani Sravanthi: No.3
Op :20230537092
35 F came to opd with  c/o dragging type of pain over B/l upper limbs and lower limbs since 2 yrs.
C/o headache on and off since 2 yrs , diffuse in nature ,not a/w nausea and vomitings
Palpitations (+)
H/o fasciculations in the both hands, nerve conduction studies done -normal in study.
Past history:
Diagnosed as Right sided fibroedenoma with galctorrhoea 4 yrs back. Fibroedenoma was resected 1 yr back.
N/k/o htn,dm,thyroid,epilepsy,tb

VITALS:
BP: 110/80mm hg
Pr : 68bpm
Rr: 16 cpm
No pallor,icterus,cyanosis,clubbing,lymphadenopathy,edema

 R.s:bae+,nvbs
Cns:nfnd
Cvs:s1s2heard,no murmers
P/a:soft,non tender

 Local examination:
Lump + in right upper quadrant of breast, soft in consistency, no tenderness, no local rise of temperature ,with galctorrhoea.

Provisional diagnoses:
Generalized weakness /lethergy,
H/o fibroadenoma with galctorrhoea suspected prolactinoma used cabergoline.

Patient is advised for admission.

[23/05/23, 12:12:59 PM] Kshitij Sharma: Okay sir!

[23/05/23, 12:19:30 PM] Rakesh Biswas Sir: Only three since morning!!

[23/05/23, 12:50:10 PM] ~ Basani Sravanthi: No.4
Op :20230537713
28 F came to opd with  c/o pain in the epigastric region on and off since 1 month, intertermittent in nature,pricking type.
C/o SOB on exertion since 1 month, insidious in onset, relieved after taking rest.
No H/o chest pain, palpitations , sweating,
No h/o burning micturition, decreased urine output.
No h/o fever,cold,cough
Past history:
N/k/o htn,dm,thyroid,epilepsy,tb
VITALS:
BP: 90/70mm hg
Pr : 88bpm
Rr: 16 cpm
  No pallor,icterus,cyanosis,clubbing, lymphadenopathy,edema

 R.s:bae+,nvbs
Cns:nfnd
Cvs:s1s2heard,no murmers
P/a:soft, and 
     tenderness in the epigastric region.

 Patient is advised for admission not willing for admission.

[23/05/23, 12:51:37 PM] Rakesh Biswas Sir: Here is a link : http://medicinedepartment.blogspot.com/2020/05/informed-patient-consent-and.html?m=1,

we regularly use for every patient/relative to download and provide their informed signature  after proper reading of the form along with asking us questions and they finally share back the signed image to our residents who keep the document confidential and safe.

[23/05/23, 12:51:38 PM] Rakesh Biswas Sir: Download the BMJ consent form from here :

https://authors.bmj.com/policies/patient-consent-and-confidentiality/

[23/05/23, 12:51:39 PM] Rakesh Biswas Sir: https://userdrivenhealthcare.blogspot.com/2022/09/deidentifying-and-anonymizing-patient.html?m=1

[23/05/23, 12:54:30 PM] ~ Rachana Gangula: No.6 
Op : 20230537794
22/F 

C/o headache on and off since 2 yrs , diffuse in nature ,a/w nausea 
Eye strain + Photophobia + Phonophobia + 
Headache increased since 3 days 
Not associated with blurring of vision or giddiness or vomitings. 
H/O fall from bike 6 years ago in RTA. No trauma to head. No ENT bleed, Loss of consciousness.  

N/k/o htn,dm,thyroid,epilepsy,tb

VITALS:
BP: 100/70mm hg
Pr : 77bpm
Rr: 17 cpm
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

 R/S- bae+,nvbs
CNS -nfnd
CVS- s1s2heard,no murmers
P/A- soft,non tender

Patient is advised for admission but not willing for admission as patient came alone and attender is not present

[23/05/23, 2:20:26 PM] ~ Basani Sravanthi: No.7
Op :20230537785
14 F came to opd with  c/o cough which is productive since 3 days. Sputum is scanty, mucoid,white in colour.
C/o cold since 3 days, sneezing +.
No h/o fever, burning micturition.
No H/o chest pain, palpitations , sweating,
 
Past history:
N/k/o htn,dm,thyroid,epilepsy,tb
VITALS:
BP: 100/60mm hg
Pr : 106bpm
Rr: 16 cpm
  No pallor,icterus,cyanosis,clubbing, lymphadenopathy,edema

 R.s:bae+,nvbs
Cns:nfnd
Cvs:s1s2heard,no murmurs
P/a:soft, and non tender
    
Patient is advised for admission not willing for admission.

[23/05/23, 2:54:39 PM] ~ Basani Sravanthi: No.8
Op :20230538194
40 M came to opd with  c/o vomiting (multiple episodes)  since 3 days. 1 -2 times a/w bile.
C/o hiccups since 3 days.
C/o low grade fever.
No h/o pain abdomen,loose stools
F/o case of bile reflux gastritis with hiatus hernia with reflux gastropathy
Past history:
N/k/o htn,dm,thyroid,epilepsy,tb
VITALS:
BP: 130/80mm hg
Pr : 78bpm
Rr: 16 cpm
  No pallor,icterus,cyanosis,clubbing, lymphadenopathy,edema.
R.s:bae+,nvbs
Cns:nfnd
Cvs:s1s2heard,no murmurs
P/a: Appears dehydration.
No tenderness.
    Patient is getting admitted.

[23/05/23, 3:03:58 PM] ~ Rachana Gangula: Sno 10
Op no 20230538919
42/M 

C/o diarrhea since 1 week around 5 episodes/day 
C/O vomitings since 1 week around 3-4 episodes/ day 
Food as content, Non-projectile, Non-Bilious

Fever since 3-4 days
associated with chills and rigor 
H/O trauma (fall) one week back No LOC, No giddiness no ENT bleed 
C/o Lethargy since 1 week 

N/K/C/O HTN, DM, TB, Asthma,CAD,CVA, Epilepsy, Thyroid Disease 

Vitals:
Bp:100/50mmhg
Pr:90bpm
Rr:80cpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R/S- BAE,NVBS heard


Patient advised admission for further evaluation but not willing for admission.

[23/05/23, 3:08:55 PM] ~ Rachana Gangula: Sno 11
Op no 20250537727
45/F 

C/O Epigastric pain since 2 months
C/O burning sensation in epigastric region 
Burning sensation Relieved on taking food.

K/C/o HTN since 6 years and on regular medication 

N/K/C/O DM, TB, Asthma,CAD,CVA

VITALS:
BP: 110/70mm hg
Pr : 77bpm
Rr: 17 cpm
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

 R/S- bae+,nvbs
CNS -nfnd
CVS- s1s2heard,no murmers
P/A- soft,non tender

Patient is advised for admission but not willing for admission.

[23/05/23, 3:31:08 PM] ~ Basani Sravanthi: No.12
Op :20230536665
47 F came to opd with  c/o SOB since 2 month,increased since 2 -3 days. More on exposure to cold water and fine dust .
SOB lasting for 30 mins ( now inhaler frequency increased but no relief) a/w wheeze.
Past history:
H/o similar complaints 6 mns back used nebulizer /inhaler and relieved.
Last inhaler used 15 days back.
-N/k/o htn,dm,thyroid,epilepsy,tb
VITALS:
BP: 140/90mm hg
Pr : 90bpm
Rr: 16 cpm
  pallor +
No icterus,cyanosis,clubbing, lymphadenopathy,edema.
R.s:bae+,nvbs, no wheeze
Cns:nfnd
Cvs:s1s2heard,no murmurs
P/a: soft and non tender.
 Patient is advised for admission, but not willing for admission.

[23/05/23, 4:25:53 PM] Rakesh Biswas Sir: Only 12 patients seen in opd today ?

[23/05/23, 4:34:32 PM] ~ Rachana Gangula: Sno 13
Op no 20210204066
29/M 


clo fever with body pains since 2 days
C/o throat pain on swallowing
fever with evening rise of temperature 
high grade, intermittent 
Associated with chills and rigor. Nausea present 
no c/o sob, cold, cough, pain abdomen.


N/K/C/O HTN DM, TB, Asthma,CAD,CVA

VITALS:
BP: 120/70mm hg
Pr : 76bpm
Rr: 17 cpm
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

 R/S- bae+,nvbs
CNS -nfnd
CVS- s1s2heard,no murmers
P/A- soft,non tender
local examination - no congestion of throat.

Patient is advised for admission but not willing for admission.

[23/05/23, 5:17:57 PM] Lohith Pg Gm : 1 admission from OP sir

[23/05/23, 7:03:46 PM] Rakesh Biswas Sir: Thanks! How many cases seen in opd today?






24th May 2023,Wednesday 

[24/05/23, 11:00:15 AM] ~ Navya: Op no. 20210118247
60/F
C/O chest pain since 10 days
(Right side and restrosternal) 
No radiation of pain, no chest tightness, no sob, palpitations, giddiness. 
H/O cough since 1 year(on herbal medication) 

N/k/o HTN, DM,epilepsy,asthma thyroid,CVA

Vitals:
Bp:120/80mmhg
Pr:96bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:NVBS heard, decreased breath sounds in Right ISA, IAA

Patient is advised for admission but not willing for admission

[24/05/23, 11:06:10 AM] ~ Navya: 2.
Op no. 20230538522
40/M
C/O chest pain since 20 days, left sided, radiating to lt upper limb, palpitations present, pain more after eating food. 
N/H/O sob, pedal edema, giddiness
H/O 2 episodes of tremors and weakness on working in sunlight. 
N/H/O vomitings/loose stools
H/O 2 episodes of high BP(200/120) and used medication
N/k/o HTN, DM,epilepsy,asthma thyroid,CVA

Vitals:
Bp:108/78mmhg
Pr:76bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:BAE,NVBS heard

Patient is advised for admission but not willing for admission

[24/05/23, 11:06:22 AM] ~ A.R.T.TEJASRI: op no :2023053852
75/M
c/o fever since 10 days, high grade associated with chills and rigors , no diurnal variation, relieved with medication
Cough since 1 week , productive, more during day time
N/H/O SOB,Vomiting,chestpain, loosesttols, pain abdomen
not a clinical daze of DM ,HYN, THyroid, CAD, Seizures 
O/E c/c/c
afebrile
PR 96 bpm
BP-100/60
CVS- S1,S2+
RS - BAE + , NVBS ,decreased breath sounds at IAA , ISA
h/o similar complaints 4 months ago relieved after medication

[24/05/23, 11:06:55 AM] ~ A.R.T.TEJASRI: patient is advised for admission not willing

[24/05/23, 11:11:22 AM] ~ A.R.T.TEJASRI: op no :20230539499
c/o pain in abdomen since 2 days
pain in lower abdomen(rif,lif,hyponchondrium), spasmodic ,intermittent,  colic type increased intensity and frequency since 2days
h/o gall stones 6mm without cystitis 6 months back
denovohypertension with dyspepsia
advised T.buscopan po/bd for 3 days

[24/05/23, 11:16:59 AM] ~ Navya: 5.
Op no. 20230538950
30/F
C/O unintentional weight loss since 6 months
(>8 kg weight loss) 
C/O constipation since 10 months(on homeopathic medication) 
H/O surgery for hemorrhoids 8 months ago
H/O excessive hair fall
N/H/O Fever, cough, sob
N/H/O blood loss in stools, abdominal pain, 
Normal apetite
H/O oral ulcers

N/k/o HTN, DM,epilepsy,asthma thyroid,CVA

Vitals:
Bp:90/60mmhg
Pr:88bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:BAE,NVBS heard

Patient has advised tab. Orofer xt po/of for 15 days.

[24/05/23, 11:29:00 AM] ~ Navya: 6.
Op no. 20230538933
37/M
C/O both lower limb swelling since one month
C/O burning sensation in chest since one month
H/O atrophic pancreas with pancreatic duct calculi since 2021 and on pancreatin 300 mg and esmaprazole 20 mg
But stopped medication one month back since then pedal edema and burning sensation in chest increased
K/c/O DM since 10 years and on inj. Mixtard
H/O erectile dysfunction since 2 months
H/O bulky stools present

N/k/o HTN, epilepsy,asthma thyroid,CVA

Vitals:
Bp:100/60mmhg
Pr:78bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:BAE,NVBS heard

Provisional diagnosis:? GERD with chronic pancreatitis

Patient is advised for admission but not willing for admission

[24/05/23, 11:36:27 AM] ~ Navya: 7.
Op no. 20230538966
75/M
C/O fever since 4 days, high grade, associated with chills and rigors , relieved with medication
Throat pain during swallowing present
N/h/O cough. Cold
Sob 1 week back relieved after treatment at RMP
K/C/O HTN since 6 years and on medication and DM-2 since 6 years and on glimiM1 po/od

Vitals:
Bp:110/80mmhg
Pr:92bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:BAE,NVBS heard

Patient is advised for admission but not willing for admission

[24/05/23, 11:44:48 AM] ~ Navya: 8.
Op no. 20230539475
73/M
K/C/O epilepsy on tab. Levipil, last episode in 2020
K/C/O HTN since 30 years on tab. Telma AM
No h/O FND
Last MRI brain 2020:-b/l microhemorrhages in thalamus and ganglia
C/O one episode of vasovagal syncope while urinating at night. 
One episode of sweating, giddiness, without lossof consciousness, without fnd, no seizures, lasting for 10 min 

O/E 
Gait:- normal
Tone:-b/l upper limb and lower limb-normal
Power:-5/5 in all limbs
Reflexes :-2+

Vitals:
Bp:130/80mmhg
Pr:78bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
R.s:BAE,NVBS heard

Patient is advised for admission but not willing for admission

[24/05/23, 12:02:38 PM] ~ A.R.T.TEJASRI: 9.
OP no.20230538960
45/M
c/o giddiness since2 weeks,intermittently occurring,aggravating on getting up from sitting position or changing head position 
c/o blurring of vision from 5years,which has increased following giddiness
c/o b/l pedal edema from 1year,pitting type,occurring intermittently 
c/o occasional sob,grade2 from 1year
no h/o vomitings with giddiness,no h/o reduction in urine volume 

N/k/o HTN, DM,epilepsy,asthma thyroid,CVA

Vitals:
Bp:120/80mmhg
Pr:68bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:NVBS heard, BAE present
provisional diagnosis:-?BPPV

Patient is advised for admission but not willing for admission

[24/05/23, 12:17:14 PM] ~ A.R.T.TEJASRI: 10.
OP no.20230538962
40/F
c/o chest pain since 6 years,on and off,right and left side,no radiation of pain, pain more after eating food,burning sensation in the chest present.
h/o execessive weight(97kgs) gain,occasional sob on exertion.no orthopnea,wheeze
h/o hairloss present
n/h/o pedal edema,palpations

N/k/o HTN, DM,epilepsy,asthma thyroid,CVA

Vitals:
Bp:130/80mmhg
Pr:88bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:NVBS heard,bae present

6 min walk test:-
after 4min of walking,she's complaining of sob
pr:-
before 6 min walk -100bpm
after 6 min walk-122bpm

Patient is advised for admission but not willing for admission

[24/05/23, 12:19:17 PM] ~ Navya: 11.
Op no. 20230536663
55/M
f/c/o TB peritonitis  (low SAAG,high protein)on ATT with cld
came for regular checkup.
c/o epigastric pain after eating food
occasional pedal edema present,more in the evening, relieved by morning 


N/k/o HTN, DM,epilepsy,asthma thyroid,CVA

Vitals:
Bp:120/80mmhg
Pr:86bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:NVBS heard, bae present

Patient has advised TAB.akurti -3 po/od  and tab.benadon 40mg po/od

[24/05/23, 12:23:18 PM] ~ Navya: 12.
Op no. 20230538935
21/M
C/O fever since 3 days
C/O redness of both eyes since 5 days
C/O cold and sore throat since 3 days
C/O 1 episode of vomiting yesterday
Fever-high grade, intermittent, a/w headache, cold, cough, body pains

N/k/o HTN, DM,epilepsy,asthma thyroid,CVA

Vitals:
Bp:110/60mmhg
Pr:110bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:BAE,NVBS heard

Provisional diagnosis:-
?viral pyrexia
?URTI
?allergic conjunctivitis

Patient is advised for admission but not willing for admission

[24/05/23, 12:32:30 PM] ~ Navya: 13.
57/M
B/Lower limb swelling from knee-ankle (pitting type) more on walking, present occasionally at rest. 
No sob, chest pain. 
Non smoker
O/E:-
B/l calf tenderness present
No restriction of joint movements
No local rise of temp
Peripheral pulses felt
No discoloration

ABI :-100/140=0.7

Provisional diagnosis:-? PAD claudication pain

Patient is advised for admission but not willing for admission
[24/05/23, 2:15:40 PM] ~ Navya: 14.
50/F
C/O both lower limb swelling since20 days
H/O right lowerlimb filariasis since 25 years
C/O decreased urine output
Since 20 days
H/O burning micturition on and off
N/K/C/O HTN, DM, Asthma, TB, epilepsy
She was told to have kidney disease 1 year back

O/E:-
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:BAE,NVBS heard

Advised tab. Lasix40mg  po/bd 
Patient is advised for admission ,she will come on next Wednesday for admission

[24/05/23, 2:26:42 PM] ART: op  no :20230538951
A 43F
Taylor 
c/o giddiness since 2-3months
fever since 10 days 
b/l lower limb swelling since 3 days
Giddiness occurs for 5-10seconds aggravates on standing resolves by itself
fever is low grade intermittent  
b/l lowerlimb swelling 3 days back till above ankles decreased gradually h/o decreased urine output 
burning micturition 
o/e pt is c/c/c
cvs - s1s2+
rs bae+, nvbs
perabdomen soft, non tender 
cns tinnitus + 
nystagmus negative 
tone normal in all four limbs
pper u/l 4/5   4/5
   l/l   4/5 4/5
reflexes B(2+,2+), T(2+,2+),S(2+,2+),K (2+,2+),A(+,+), p ( f,f)
gait normal 
tandem walk normal

advised for admission not not willing for admission as she has kids at home

[24/05/23, 2:51:00 PM] ART: op no :20230540066
complaints of headache since 2 years
b/l frontal pain 
c/o neckpains radiating to shoulder joint associated with photophobia, lhonophobia, no aura no giddiness
o/e ccc
afebrile 
bp-120/80
pr- 84/mon
CVS-s1,s2+
no murmurs
Rs bae+, nvbs
LE: sinuses normal

[24/05/23, 2:52:16 PM] ART: 27 F advised admission not willing to admit

[24/05/23, 2:58:48 PM] Rakesh Biswas Sir: What was her daily routine two years back and how was that disrupted?

[24/05/23, 3:16:55 PM] ART: op no:20230540088
10 M
c/o burning sensation in the bilateral palms and execessive sweating in bilateral palms and soles since 2 years
walking on wool like sensation present
distal paresthesia with isolated hyperhidrosis secondary to ?vitamin b12 deficiency?
rombergs negative
decreased finetouch and decreased proprioception in  dip,mtp
motor 
power 5/5 in all four limbs
tone normal in all four limbs
reflexes 
btska(2+,2+,3+,3+,2+,2+,3+,3+,2+2+, plantar flexor
advised admission  , will come tomorrow for admission.

[24/05/23, 3:26:43 PM] ART: op no 20230540093
45/F
c/o tingling and numbness, all over the body more in palms
tingling sensation is more during  exertion.
no h/o weakness, giddiness,difficulty in walking, no h/s/o loss of sensation.
not a clinical case of, DM, HTN, TB , asthma , epilepsy
o/e
c/c/c
afebrilePR-88
BP-130/80mmhg
CVS- S1,S2+, No murmurs
RS- BA E +,NVBS 
pA- soft no tender

[24/05/23, 3:30:12 PM] Rakesh Biswas Sir: Since when? 

What was her daily routine before that and how was that disrupted since her symptoms began?

[24/05/23, 4:06:41 PM] ART: 28F
OPNO: 2023440089
complaints of generalised weakness since 1 week
low grade fever with lesions( resolved ) in angle of mouth, bitterness in mouth
similar complaints since 1 month
right ear infection on treatment since 20 days fungal spores( resolving)
also being treated for bilateral pterygium inflamed in both eyes( resolved)
o/e 
mild pallor +
oral cavity: right tonsillar hypertrophy, no congestion, no lymphadenopathy

[24/05/23, 4:07:28 PM] Rakesh Biswas Sir: Fungal spores? 

How were they isolated?
[24/05/23, 4:18:32 PM] ART: otomycosis sir .. it can be seen in ear canal ..

[24/05/23, 4:24:11 PM] Rakesh Biswas Sir: Yes but that's a clinical assumption not a organismal diagnosis? Any clinical image of that for this patient?






25th May 2023,Thursday

[25/05/23, 9:33:11 AM] ~ Pranati: Serial no.1
op no 20210524998
41/M
c/o left sided chest pain since today morning radiating to left shoulder and left side of neck.
no h/o SOB,palpitations, giddiness, PND,orthopnea, fever.
C/O generalised weakness since today morning.
No nausea or vomiting
Not a clinical case of, DM, HTN, TB , asthma , epilepsy,CVA,CAD,thyroid disorders
o/e
c/c/c
afebrilePR-88
BP-130/80mmhg
CVS- S1,S2+, No murmurs
RS- BAE +,NVBS 
pA- soft no tender

[25/05/23, 9:36:08 AM] ~ Pranati: Patient was adviced for admission but patient not willing to admit.

[25/05/23, 9:46:12 AM] Rakesh Biswas Sir: Clinically what does the chest pain look like? 

Get an ECG 

Share the clinical images of his visceral fat and biceps and chest with a pointer around the pain area

[25/05/23, 9:50:18 AM] Rakesh Biswas Sir: OK mention in the opd ticket that while there are no current gross changes of myocardial infarction the patient needs admission for a chance that it may evolve further

[25/05/23, 9:50:47 AM] Rakesh Biswas Sir: Thanks

Always take this image in standing

[25/05/23, 9:51:51 AM] ~ Pranati: Okay sir

[25/05/23, 9:53:03 AM] Rakesh Biswas Sir: Lateral view

[25/05/23, 10:12:37 AM] ~ Pranati: Serial no 2
Op no 20230540007
C/O facial puffiness
no c/o decreased urine output.
Tailor by occupation
Pedal edema after walking
C/o headache - frontal region only increased on working
no c/o chestpain , sob, palpitations,
Orthopnea , PND.
no c/o fever,pain abdomen, burning micturition.
not a clinical case of, DM, HTN, TB , asthma , epilepsy,CBA,CAD,thyroid disorders
Hysterectomy done 15 years back.
o/e
c/c/c
afebrilePR-88
BP-130/80mmhg
CVS- S1,S2+, No murmurs
RS- BA E +,NVBS 
pA- soft no tender
Patient was adviced for admission but patient not willing to admit.

[25/05/23, 10:15:50 AM] Rakesh Biswas Sir: Today the sharings have improved? 

[25/05/23, 10:15:53 AM] ~ Rishitha: Serial no.3
op no 20230540366
45/M

C/o decreased appetite since 2-3 days
C/o pain abdomen since 1 month pricking type in lumbar region
Vomitings since 6 days 
3-4 episodes
non-projectile, non bilious, with food particles as contents non blood stained.
productive couch since 2 days
whitish mucoid sputum.
No c/o fever
C/o pedal edema pitting type extending upto knee exaggerated by walking relieved on lying down

Not a known case of DM, HTN, TB,asthma , epilepsy,CVA,CAD,thyroid disorders
o/e
c/c/c
afebrile
PR-82bpm
BP-120/80mmhg
CVS- S1,S2+, No murmurs
RS- BAE +,NVBS 
pA- soft, tenderness in right iliac region,obese
Patient was advised admission,will come on Saturday for admission

[25/05/23, 10:22:53 AM] ~ Rishitha: Serial no.4
op no 20210210383
59/M
C/o burning micturition since 1 and half month
No c/o decrease in urine output
Non foul smelling,no hematuria
Occasionally c/o frothy urine
Nocturia present
No c/o fever,loose stools,vomitings
K/c/o HTN since 2 yrs(on tab.amlodipine 5mg)
Not a known case of DM,TB,asthma , epilepsy,CVA,CAD,thyroid disorders
o/e
c/c/c
afebrile
PR-76bpm
BP-130/80mmhg
CVS- S1,S2+, No murmurs
RS- BAE +,NVBS 
pA- soft,non tender
B/L pedal edema pitting type till mid calf
Patient was advised admission,and getting admitted

[25/05/23, 10:36:07 AM] ~ Rishitha: Serial no.5
op no 20210118247
60/F
C/o chest pain(retrosternal) since 10 days
Non radiating intermittent no local tenderness 
Not associated with sob,palpitations,syncopal attacks,sweating 
Pain not increased or decreased on exertion 
Not a known case of HTN,DM,TB,asthma , epilepsy,CVA,CAD,thyroid disorders
No H/O blood loss
o/e
c/c/c
afebrile
PR-80bpm
BP-110/60mmhg
CVS- S1,S2+, No murmurs
RS- BAE +,NVBS 
pA- soft,non tender
B/L pedal edema pitting type till mid calf
Patient was advised admission,but not willing to get admitted

[25/05/23, 10:54:28 AM] ~ Rishitha: Serial no.6
op no 20230540867
45/M
C/o tingling sensation in both the palms since 1 year
aggravated on riding bike or on pressure 
Relieved after taking rest
B/L knee pain since 2 months intermittent 
Not increased or decreased on doing work
Not a known case of HTN,DM,TB,asthma , epilepsy,CVA,CAD,thyroid disorders
o/e
c/c/c
afebrile
PR-88bpm
BP-120/80mmhg
CVS- S1,S2+, No murmurs
RS- BAE +,NVBS 
pA- soft,non tender
CNS
Sensory examination -fine touch present
Vibration normal 10secs on both mcp
Proprioception present
Crude touch present
Pain present
Temperature  normal
Patient was advised admission to evaluate paresthesias,but not willing to get admitted
[25/05/23, 11:07:37 AM] Rakesh Biswas Sir: Clinical images of visceral fat and biceps lateral view?

[25/05/23, 11:11:27 AM] ~ Pranati: Serial no.7
Op no 20210502855
C/O heaviness of chest since 10-15 days with cough(dry) occasionally with sputum blood tinged
Chest heaviness a/w sweating, SOB
Numbness of right leg since one week a/w tingling sensation.
SOB aggravated on exertion and relieved after taking rest
no h/o fever, loss of appetite
Smoker- daily 2-3 chuttas per day since 40 years
Toddy drinker
not a clinical case of, DM, HTN, TB , asthma , epilepsy,CVA,CAD,thyroid disoreders
Patient was adviced for admission for cardiac evaluation but patient not willing to admit.

[25/05/23, 11:36:27 AM] ~ Pranati: Serial no.8
Op no 20230540874
C/O fever since one week low grade, continuous, relieved by medication not a/w chills and rigors.
C/O right loin pain since 10 days.
C/O burning micturition
Normal urine output
Nausea+ ,vomitings+
C/O decreased appetite
No c/o pain abdomen, SOB
not a clinical case of, DM, HTN, TB , asthma , epilepsy,CVA,CAD,thyroid disorders
Patient was adviced for admission for further evaluation of fever but patient not willing to admit.

[25/05/23, 11:45:09 AM] ~ Rishitha: Serial no.9
op no 20230540876
45/M

C/o bilateral pedal edema pitting thpe till knees since 1 month
Facial puffiness 1 month back
Foul smelling urine
H/o fever with chills 1 month back for 3 days relieved after taking medication 
No c/o decreased urine output,hematuria
H/o left CVA 3 years back
Not a known case of HTN,DM,TB,asthma , epilepsy,CVA,CAD,thyroid disorders
O/E
No raised jvp
CNS-
HMF intact
Pupils-B/L NSRL

TONE:   RT.              LT

        UL NORMAL.    DECREASED

        LL NORMAL      DECREASED

POWER:

        UL  5/5.          3/5   

        LL  5/5.          3/5

REFLEXES:

        B:   2+         -

        T:   2+         -

        S:   2+         -

        K:   2+        -

        A:   2+        -

        P:   Flexion. Extension

Patient was advised admission to evaluate ?AKI but not willing to get admitted

[25/05/23, 12:01:54 PM] ~ Pranati: Serial no.10
Op no 20230541396
C/O low backache since one week , non radiating.
C/O left loin pain non radiating since 5 days.
Constipation since 1 week
Pain abdomen (diffuse) squeezing type 1 week back, now relieved.
No fever, cough , SOB, vomitings
Known case of DM, HTN since 10 years and on medication not known
H/O CVA (left hemiparesis) 10 months back. (?Hypertensive bleed)
Patient was adviced for admission for further evaluation but patient not willing to admit.

[25/05/23, 12:02:58 PM] ~ Rishitha: Serial no.11
op no 20230535904
45/F
C/o headache with neckpain since 1 month
Associated with blurring of vision
Not a/w phonophobia,tinnitus,diplopia,lacrimation
Headache not increased/decreased with change in position
Headache relieved after taking medication and not relieved after taking rest
Not a known case of HTN,DM,TB,asthma , epilepsy,CVA,CAD,thyroid disorders
Patient was advised admission for further evaluation but not willing to get admitted
[25/05/23, 12:19:14 PM] ~ Rishitha: Serial no.12
op no 20230541388
47/M
C/o headache in parietal region since 10-15 days sometimes radiating to occipital region
Associated with giddiness,diplopia and blurring of vision
Associated with neck pain
Headache lasting for 20 mins relieved on itself.no medications used
No tingling sensation,numbness
K/c/o DM2 on medication since 1 yr(T.Metformin 500mg PO OD)
Not a known case of HTN,TB,asthma , epilepsy,CVA,CAD,thyroid disorders
Patient was advised admission for further evaluation of headache but not willing to get admitted

[25/05/23, 12:35:35 PM] ~ Pranati: Serial no.13
28/F
Op no 20230541425
C/O cough since 3-4 months with sputum (whitish colour, non foul smelling and not a/w blood)
More in the night a/w cold
No h/o decreased appetite, SOB, palpitations, fever, weight loss/gain
K/c/o hypothyroidism since 7 years on T.thyronorm 50mg
not a clinical case of, DM, HTN, TB , asthma , epilepsy,CVA,CAD.
Patient was adviced for admission for further evaluation but patient not willing to admit.

[25/05/23, 12:45:54 PM] ~ Rishitha: Serial no.14
op no 20230541450
45/F
C/o pain in left side of head,left facial pain,left side of chest,left hand and left leg since 2 years
Tingling sensation present in left hand and leg
Indigestion,burning type of sensation 
headache with giddiness sometimes 
No h/o loc,nausea,vomitings
C/o decreased urine output,burning micturition,?urinary incontinence
C/o low backache on and off since 2 years
Not a known case of DM,HTN,TB,asthma , epilepsy,CVA,CAD,thyroid disorders
Patient was advised admission for further evaluation of ?UTI but not willing to get admitted

[25/05/23, 1:06:53 PM] ~ Pranati: Serial no.15
28/F
Op no 20230540863
C/O headache in occipital region since 7 months a/w neck pain a/w tingling sensation in right upper limb.
No c/o diplopia
No c/o photophobia /phonophobia / lacrimation / nausea
No c/o giddiness
not a clinical case of, DM, HTN, TB , asthma , epilepsy,CVA,CAD.
Patient was adviced for admission for further evaluation but patient not willing to admit.

[25/05/23, 2:54:29 PM] ~ Rohith Dharma: Serial no.16
op no 20230541895
67/M

C/o slurring of  speech since 4am today morning 
Deviation of mouth present 
No drooling of saliva 
Tingling sensation and pain  in left upper limb since 5 days 
No c/o weakness in all limbs 
No c/o loss consciousness
No c/o seizures ,headche, neckpain, giddiness 
Not a known case of HTN,DM,TB,asthma , epilepsy,CVA,CAD,thyroid disorders
O/E
CVS - s1 s2 heard, no murmurs
RS - BAE + , NVBS + ,no added sounds 
CNS - 

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:   +        -

        A:   +        -

        P:   Flexion. Flexion

Patient was advised admission for further evaluation but patient  not willing to get admitted advised for neurology opd on next Thursday

[25/05/23, 3:12:04 PM] ~ Rohith Dharma: Serial no.17
70/F
Op no 20230547818

C/O pedal edema pitting type till knees since 1  month
 Facial puffiness present 
B/l lower limb pain since 1 month 
Right loin pain radiating to groin since 1 month 
No c/o decreased urine, frothy urine , hematuria negative 
H/o of breast carcinoma 3 years back ( mastectomy done )
H/o renal calculi since 1 year 
K/c/o Hypertension since 6years and DM 5 years 
O/e 
Patient was c/c/c 
CVS - s1 s2 heard, no murmurs
CNS - NAD 
RS - BAE+,NVBS
Patient was adviced for admission for further evaluation but patient not willing to admit.

[25/05/23, 3:27:08 PM] ~ Rohith Dharma: Serial no.18
33/F
Op no 20230541901

C/O chest pain  since 2 to 3 months 
 Dragging type of pain
Relieved on taking rest 
Heart burn present,retrosternal pain present 
Shortness of breath grade 2 - sometimes
No c/o palpatations,orthopnea,PND 
No giddiness , sweating 
Present similar complaints at past
N/K/c/o Hypertension, DM,TB epilepsy,CVA,CAP,Bronchial asthma,thyroid disorders 
O/e 
Patient was c/c/c 
CVS - s1 s2 heard, no murmurs
CNS - NAD 
RS - BAE+,NVBS
Patient was adviced for admission for further evaluation but patient not willing to admit.

[25/05/23, 3:38:53 PM] ~ Rohith Dharma: Serial no.19
40/F
Op no 20230541919

C/O headche- holocranial  since 3 months 
 Pulsatile in nature radiating towards left ear 
Earache present since  1 month
No discharge from ear
No C/o hearing loss
Tinnitus present
Neck pain present 
No h/o loss of consciousness, seizures,giddiness 
N/K/c/o Hypertension, DM,TB epilepsy,CVA,CAP,Bronchial asthma,thyroid disorders 
O/e 
Patient was c/c/c 
CVS - s1 s2 heard, no murmurs
CNS - NAD 
RS - BAE+,NVBS
Patient was adviced for admission for further evaluation but patient not willing to admit

[25/05/23, 3:39:29 PM] ~ Rishitha: Serial no.20
op no 20210313182
53/M
C/o fever with chills since 8 days
Intermittent,no diurnal variation,relieved after taking medication 
Decreased appetite+,nausea+,burning micturition+
Yellowish colour non foul smelling urine
Dry cough(intermittent)since 5 days
K/c/o HTN since 3 years on tab.Telma 20mg
Not a known case of DM,TB,asthma , epilepsy,CVA,CAD,thyroid disorders
O/e 
Patient was c/c/c 
CVS - s1 s2 heard, no murmurs
CNS - NAD 
RS - BAE+,NVBS
Patient was advised admission for further evaluation but not willing to get admitted

[25/05/23, 4:32:01 PM] Rakesh Biswas Sir: How many seen and how many admitted ?

[25/05/23, 5:51:59 PM] Lohith Pg Gm : 22-23 patients were seen. 
1 admission sir






26th May 2023,Friday

[26/05/23, 9:59:46 AM] ~ Tharunkumar: 1.Op no:20210420287
75/M 
C/o cough since 2-3 months associated with sputum, whitish,non blood stained,no diurnal variation associated with SOB Grade 2-3 ,no orthopnea, no PND ,no pedal edema 
No H/o fever 
C/o decreased urine output, burning micturition 
K/c/o HTN since 2
10 yrs and on regular medication Telma kind-H
N/k/c/o DM,TB, epilepsy and asthma 
Daily routine -
Wakes at 6am eats breakfast and goes for farming and lunch at 1pm(rice and curry) and takes rest in the afternoon and dinner at 8pm(Roti) and sleeps at 9pm.
CVS- S1 S2 heard no murmurs
RS-BAE+ NVBS  
Wheeze present in right IMA,ISA and left IMA,ISA
P/A- soft non tender 
CNS-NFND 
Patient was advised admission but not willing as he came only for tests

[26/05/23, 10:01:38 AM] Rakesh Biswas Sir: Share his clinical images with visceral fat and muscle mass

[26/05/23, 10:08:27 AM] Deepthi Ma’am : 2.Op no:20210223311
52 M  
C/o  fever since3-4days associated with chills and rigors
C/o cough  which is non productive c/o heartburn occasionally
No c/o sob ,orthopnea,pnd
No c/o vomiting,diarrhea 
C/o of decreased urine output
C/o burning micturition since 15days
H/0renal calculi
N/k/c/o DM,HTN
Daily routine :wakes up at 7:00am, ,takes breakfast at 8:00am ,lunch at12pm
Goes to work comes back at 5:00pm,takes dinner chapati and curry at9:000pm sleeps at 10pm
No change in daily routine
O/E :
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt
Patient is advised for admission but not willinng

[26/05/23, 10:23:10 AM] ~ Tharunkumar: Op no:20230542255
43/F
C/o distension of abdomen since 20 days, insidious onset gradually progressive. 
C/o swelling over the B/L DIP,PIP and wrist joint not associated with pain.
No H/o fever,cough,cold,pain abdomen
No c/o decreased urine output, burning micturition 
K/c/o hypothyroidism since 5 years on T. Thyronorm 25mcg
N/k/c/o DM,HTN,TB, epilepsy and asthma 
CVS- S1 S2 heard no murmurs
RS-BAE+ NVBS  
P/A- soft  tenderness present over left iliac region 
Shifting dullness absent 
CNS-NFND 
Patient was advised admission but not willing for admission as she has kids at home

[26/05/23, 10:36:41 AM] ~ Tharunkumar: Op no:20210217754
45/F
C/o chest pain since 2 days, radiating to left arm, aggravating on inspiration and while doing work 
C/o low grade fever associated with dry cough 
No c/o SOB,Orthopnea,PND
No c/o burning micturition,no pedal edema
N/k/c/o DM,HTN,TB, Thyroid,epilepsy and asthma  
Tenderness present over the left 2nd and 3rd costocondral junction 
CVS- S1 S2 heard no murmurs
RS-BAE+ NVBS  
P/A- soft non tender 
CNS-NFND  
Diagnosis - ? Costochondritis  
Advised Tab.Ultracet 1/2 QID for 3 days
Patient was advised admission but not willing

[26/05/23, 10:40:16 AM] Rakesh Biswas Sir: 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

[26/05/23, 10:42:06 AM] Rakesh Biswas Sir: Who will take over from you the job of preparing this 👇

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

from next month?

[26/05/23, 10:42:50 AM] Manogyna: I can still do it myself sir

[26/05/23, 10:43:05 AM] Manogyna: Even from next month

[26/05/23, 10:43:48 AM] Rakesh Biswas Sir: Provide serial numbers 

 Please find someone who can assess each post here for the data missing as per the guidelines shared here in the description box

[26/05/23, 10:44:10 AM] Rakesh Biswas Sir: Give others a chance 🙂

[26/05/23, 10:45:12 AM] Manogyna: Okay sir😅,so should I do it till this Sunday? I will be finished Week-5 of data

[26/05/23, 10:45:40 AM] Manogyna: Finishing *

[26/05/23, 10:45:44 AM] Rakesh Biswas Sir: 👆Can you find someone to do this? 

This is the actual process of opd audit that I am currently doing single handedly now

[26/05/23, 10:46:23 AM] Manogyna: Okay sir

[26/05/23, 10:48:40 AM] Rakesh Biswas Sir: PLA R : OPD workflow audit 

Audit Platform : https://chat.whatsapp.com/EDHF6pD8BM56f371ypSrqs

Retrospective data :

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

Prospective check list and conversation transcripts for transactional knowledge👇 

[5/26, 10:40 AM] Rakesh Biswas: 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


[5/26, 10:43 AM] Rakesh Biswas: Provide serial numbers 

@918317669334 Please find someone who can assess each post here for the data missing as per the guidelines shared here in the description box



[5/26, 10:45 AM] Manogyna 2018 Kims Ug: Okay sir😅,so should I do it till this Sunday? I will be finished Week-5 of data

[26/05/23, 10:49:38 AM] Rakesh Biswas Sir: Do it till you can find and train someone else to do it well 

See one, do one, teach one

[26/05/23, 10:50:39 AM] Manogyna: Okay sir

[26/05/23, 11:06:00 AM] ~ Tharunkumar: 5.Op no:20230542633
35/M
C/o facial puffiness since 20 days with intermittent pedal edema on and off relieved on its own
C/o SOB grade 2 since 6 months
No Orthopnea,PND
No c/o decreased urine output,burning micturition
N/k/c/o DM,HTN,TB, Thyroid,epilepsy and asthma   
Addictions-Alcoholic since 15 yrs occasionally and regular since 2 years.
CVS- S1 S2 heard no murmurs
RS-BAE+ NVBS  
P/A- soft non tender 
No shifting dullness 
CNS-NFND   
Daily routine- wakes up at 5am does farming and eats breakfast,each lunch at 1pm(rice and curry) and does household work and eats dinner at 8pm and sleeps at 9:30pm.
No change in daily routine after his complaints
Patient was advised admission but not willing and he wants to after 2 days

[26/05/23, 11:07:54 AM] Deepthi Ma’am : 6.Op no2023042444
Sequence of events 
Difficulty swallowing since 1year ,
On december2022 she went to hospital ,o/E ear ,nose ,throat  was normal.s
Daily routine :wakes up at 6:oo am
Has breakfast at8:00am,has lunch at 12:00pm rice and curry ,watches tv goes to sleep at 9:oopm
 No change in daily routine


32year female who is a home maker by occupation came with c/o complaints since 1year 
C/o sore throat on and aoff
C/o giddiness 2episodes since 1year
No tinnitus 
No nystagmus
H/o weight gain 
N/k/c/o of DM,HTN,Tb,epilepsy ,asthma,thyroid
O/E 
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt


Patient is advised for admission but not willing.

[26/05/23, 11:11:22 AM] Deepthi Ma’am : 7Op no20230542587
50 M who is a farmer by occupation came with complaints of  retrosternal burning sensation since 1year
C/o regurgiattion of food since 1year which aggravates on eating spicy food
N/k/c/o DM ,HTN,tb,epilepsy,asthma
Daily routine:wakes up at 4:ooam has breakfast at 8:ooam ,goes to work , has lunch at12:oo pm(rice and curry )  watches tv, has dinner at 9:00pm 
No change in daily routine affter his complaints

O/E 
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt
Diagnosis:GERD? ?apd
Patient is advised for admission but not willing.

[26/05/23, 11:17:46 AM] Rakesh Biswas Sir: @918885066656 @918309113758 Can we explore this hypothesis that : those who may not have had any significant changes in their daily routine due to the disease are the least likely to be admitted?

[26/05/23, 11:20:40 AM] Manogyna: Yes sir

[26/05/23, 11:23:17 AM] Manogyna: Like how it might be aligning with the assumption that the disease might not be considered severe enough by patients if their Quality of life is not affected by it!?

[26/05/23, 11:28:43 AM] ~ Rithika: 8. Op no 20230542606
26M
C/o decreased appetite since 1month with significant weight loss
No h/o low grade fever , cough ,cold
No h/o constipation, diarrhoea 
Increased sleepiness present
N/k/c/o htn,dm, thyroid disorder , cad ,cva
Daily routine
3am wake up
Goes for fishing 
7 freshen up
9-10 has his breakfast 
10-1 takes rest
1-2 lunch
2-7 does electrician works
7-8 food
8-11 uses mobile and takes rest
11 sleep
No change in daily routine 
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft, tenderness over umbilical region
Patient is advised for admission but not willing.

[26/05/23, 11:38:27 AM] Kshitij Sharma: Also pt. Those who have accustomed themselves to the changes don't want to get admitted

[26/05/23, 11:41:20 AM] ~ Rithika: 9.op no.20230542255
43 F
C/o distension of abdomens since 20 days, insidious in onset and gradually progressive
C/o swelling over bilateral dip,pip and wrist joint , no pain
No history of cough, cold, fever ,burning micturition
K/c/o hypothyroidism since 5 yrs on tab.thyronorm 25 mcg
N/k/c/o htn,dm,  cad ,cva
Daily routine
5am wake up
5-6 prayers
At 7 freshens up
9 has her breakfast 
9:30 goes for supervisor work 
At 1 she has her lunch
Returns to home at 5pm
5-6 takes rest 
6-8:30 House works
8:30 lunch
9 goes to sleep
No change in daily routine 
O/E 
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft, tenderness over left iliac region
Patient is advised for admission but not willing.

[26/05/23, 12:01:47 PM] ~ Rithika: 10.op no.20230542646
66M
Complaints of pain over the scrotum which is dragging type radiating downwards since 2 months
Complaints of cough since 2 months ,dry cough
C/o sob grade 3 since 2 months, orthopnea - pnd-
Complaints of generalised itching since 5 days
(After consuming fish)
No history of cough, cold, fever ,burning micturition , decreased urine output
History of usage of ATT 6 months back
N/k/c/o htn,dm, thyroid disorder , cad ,cva

O/E 
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt
Patient is advised for admission but not willing.
[26/05/23, 12:05:03 PM] Deepthi Ma’am : 11.Op no20210124203

sequence of events
On 2020 ,patient had complaints of polyuria ,went to hospital
she was diagnosed to have diabetis
2022 ,she was diagnosed to have hypertension 
40F

 Who is a homemaker by occupation came with c/o 
Fever since 1week  which is high grade ,intermittent ,aasociated with chills, and rigors bodyache,relieved by taking medication 
C/o cough which is dry ,on and off since 1week
K/c/o HTN since 1year and on regular medication (TAB TELMA)
K/c/o DM since 3years and on medication

Daily routine:wakes up at 7am takes raagi jaava, does household work
And has lunch at1pm riceand curry 
And then watches tv has dinner at 9pm 
Appetite decreased
Sleep is disturbed


O/e:
cvs-s1s2 heard
RS-BAE +
NVBS heard
p/A -soft ,non tender 
Patient advised admission but not willing

[26/05/23, 12:20:15 PM] Deepthi Ma’am : 12Op no20230543225
34/M  
who is a old male who works in private transport office came with
C/o
 Left side headache since 10days
Headache -unilateral left sided in left fronto parietal region associated woth left retro  orbital pain
N/k/c/o DM ,HTN ,tb epilepsy, asthma,cva,cad,thyroid disorders 
Daily routine: wakes up at 6:am
Has chai biscuit goes to work ,has lunch at 1pm  ,comes back from work at 6pm then has dinner (chapati and cury )at 9 goes to sleep at 10pm


No change in daily routine,even after his complaints


Pr c/c/c 
Cvs:S1s2heard
RS:BAE + NVBs
P/Asoft nontender
Cns:NFND
Patient advised admission but not willing

[26/05/23, 12:25:11 PM] ~ Rithika: 12 . Op no 20230542615
35M
Sequence of events found to have Hypertension since 1 year on regular checkup  and on irregular medication 
C/o sob grade 2 since 1 year
Orthopnea- , pnd -
No chest pain, palpitations 
Complaints of burning micturition since one year on and off
History of renal calculi 6months back -2 mm
Known case of hypertension since 1 year and on irregular medication
Daily routine 
 6 wake up
 8 break fast
 8:30  work system
 1pm lunch rice curry
 6 returns home
 6-8 takes rest
 8 dinner(chapathi and curry)
 8-9 takes rest
 9 goes to sleep
 Feeling weakness since 1 yr 
 Difficulty in climbing stairs due to sob
N/k/c/o dm, thyroid disorder , cad ,cva
O/E 
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt
Patient is advised for admission but not willing.

[26/05/23, 12:34:21 PM] ~ Rithika: 13.op no .20210512892
39F
Complaints of fever since one week
Low grade fever ,on and off, relieved on medication associated with elbow, shoulder,knee joint pains
No retro orbital pain
No complaints of burning micturition

Known case of asthma since childhood , uses inhaler during attacks

N/k/c/o htn,dm, thyroid disorder , cad ,cva

Daily routine 
She is a homemaker by occupation 
At 6am she wakes up and does  hosehold work
11 am has her break fast 
Difficulty in doing household chores due to Fever , weakness, body pains since 10 days
2pm  lunch
Takes Rest house hold works
9 pm dinner
10 pm - sleeps

O/E 
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt
Patient is advised for admission but not willing.

[26/05/23, 12:39:08 PM] ~ Rithika: 14 . Op no 20230542663
56 M
Pt was found to have grade 1 fatty liver on  incidental checkup and patient is anxious about it  and  wanted to get it rechecked

No new complaints presently
He was counselled for dietary modification and lifestyle modification




N/k/c/o htn,dm, thyroid disorder , cad ,cva

O/E 
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt
Patient is advised for admission but not willing.

[26/05/23, 12:44:23 PM] ~ Tharunkumar: 15.Op no:20230543294
79/F
C/o Generalized body pains since 6months aggravating during night
C/o Burning micturition since 3months associated with pain during micturition 
No c/o decreased urine output 
C/o constipation since 3 months 
H/o similar complaints 4 years back admitted in our hospital 
Used Tab. Nitrofurantoin 100mg and syp.citralka
N/k/c/o DM,HTN,TB, Thyroid,epilepsy and asthma   
CVS- S1 S2 heard no murmurs
RS-BAE+ NVBS  
P/A- soft non tender 
CNS-NFND   
Daily routine- wakes up at 6am does household work and eats breakfast(Gatka), lunch at 1pm(rice and curry) and does household work and eats dinner at 8pm and sleeps at 9:30pm. Unable to do work in the evening time since 4 months and sleep is disturbed.
Patient was advised admission and getting admitted.

[26/05/23, 1:06:49 PM] ~ Rithika: 17. Op no .20230543714
30 F
Complaints of left sided headache since 6 months associated with nausea , photophobia
No phonophobia
Complaints of chest pain, non radiating type
Complaints of heartburn on increased spicy food intake 
N/k/c/o htn,dm, thyroid disorder , cad ,cva

No history of cough, cold, fever ,burning micturition
No history of  palpitations, orthopnea ,pnd.
 
Daily routine 
4:30am wakes up 
5-10am freshens up and does Household chores 
10 am break fast 
10:30  goes to  bank work (on computer)
1pm  lunch ( rice +curry)
6pm returns to home 
10pm dinner 
11 pm goes to sleep
No change in daily routine 


O/E 
Tenderness over entire chest region
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft,nt
Patient is advised for admission but not willing.

[26/05/23, 1:10:30 PM] ~ Tharunkumar: 18.Op no:20230543172
40/F
C/o Pain on left side of neck,face and left side of body since 6 days 
H/o cervical lymphadenopathy (left side) in 2012 and s/p cervical lymph node dissection 
N/k/c/o DM,HTN,TB, Thyroid,epilepsy and asthma   
O/E 
Tenderness present in left breast medial side 
Restriction of neck neck movements in left lateral flexion 
CVS- S1 S2 heard no murmurs
RS-BAE+ NVBS  
P/A- soft non tender 
CNS-NFND   
Daily routine- wakes up at 6am and goes for work,eats breakfast at around 8am and  lunch at 1pm(rice and curry) and does household work in the evening and dinner at 8pm and sleeps at 10pm. 
Unable to go for work these 7 days and daily routine is disturbed 
Patient was advised admission but not willing

[26/05/23, 2:21:26 PM] Rakesh Biswas Sir: Goes for fishing everyday at 3:00 AM? Is that his hobby or occupation?

[26/05/23, 2:22:21 PM] ~ Rithika: Occupation sir

[26/05/23, 2:24:29 PM] Rakesh Biswas Sir: @Manogyna Uploading these clinical images may be an additional work but why not establish a system of coordination between interns working from home doing the uploading and PaJR group online tasks and interns working from hospital capturing and feeding them all the necessary data including the signed informed consent forms? @Kshitij

[26/05/23, 2:25:09 PM] Rakesh Biswas Sir: Clinical images?

[26/05/23, 2:26:35 PM] Rakesh Biswas Sir: Clinical images

[26/05/23, 2:27:16 PM] Kshitij Sharma: Sir I don't think we have interns working from home.  Even Manogyna has exams from 5th June ?,! May be we can get juniors to do it?

[26/05/23, 2:27:21 PM] Rakesh Biswas Sir: Fisherman electrician?!! 

How does he catch fish?

[26/05/23, 2:27:39 PM] Kshitij Sharma: By giving electric shocks in the pond?

[26/05/23, 2:27:49 PM] Kshitij Sharma: All the fishes die and float 😂

[26/05/23, 2:27:58 PM] Rakesh Biswas Sir: Any interested medical student will be welcome

[26/05/23, 2:28:13 PM] Kshitij Sharma: Which batch is posted from 2019 batch in june sir?

[26/05/23, 2:28:26 PM] Rakesh Biswas Sir: Yes that's an illegal technique though

[26/05/23, 2:29:45 PM] Rakesh Biswas Sir: May be able to tell. Again one doesn't need to be posted to work from home?

[26/05/23, 2:30:01 PM] Kshitij Sharma: Well yes sir!

[26/05/23, 2:31:04 PM] Kshitij Sharma: May be  can add more of her classmates (interested medical students) here?

[26/05/23, 4:35:24 PM] Lohith Pg Gm : 1 admission from op sir

[26/05/23, 4:38:57 PM] Rakesh Biswas Sir: How many seen? 18?






27th May 2023,Saturday

[27/05/23, 6:31:27 AM] Rakesh Biswas Sir: Please make sure Shailaja sister puts this print out in the ICU today 

[5/26, 3:24 PM] Shailaja Sister Kims: https://www.researchgate.net/figure/Criteria-of-readiness-for-weaning-trial_tbl1_297439524

[27/05/23, 10:08:34 AM] ~ Dr.ramyareddypebbeti🩺: 1.Op no:20230544119
61/F
Came for general health checkup 
K/c/o type 2 DM since 8 yrs (on biphasic insulin)
K/c/o CKD
H/o pedal edema (on and off),till ankle ,pitting type since 5months 
H/o polyuria +
H/o tingling sensation of both upper and lower limbs 
No h/o burning micturition 
N/k/c/o HTN,TB, Thyroid,epilepsy and asthma   

O/E 
Pallor +
Oedema +
CVS- S1 S2 heard no murmurs
RS-BAE+ NVBS  
P/A- soft non tender 
CNS-
Sensory examination:
                      UL.              LL
Fine touch R :N.               N
                    L:N.                 N
Crude touch : normal on both limbs 
Pain :normal
Joint position: normal 
Vibration sensation: decreased in both lower limbs 

Patient was advised for admission  for further evaluation but want to leave and come back on Monday for admission

[27/05/23, 10:08:57 AM] ~ Rajkumar Adepu: 2 
Op no 20210500884
62/ F
Pt came for follow up
C/o pain in popliteal fossa of right lower limb since 10days
Dragging type radiating to ankle aggrevated on standing for long hours and relieved on lifting
Calf tenderness absent 
Edema /swelling of RT Lower limb absent
Difficulty in walking after standing from sitting position 
K/c/o DM 2 since 10 years on medication tab metformin 500mg po OD
K/c/o HTN since 10 years on medication telmisartan+amlodipine
K/c/o CAD post PTCA done 4 years back on medication aspirin 75 mg+ atorvastatin 20mg po OD
K/c/o hypothyroidism since 10 years on thyronorm 100mcg

O/e 
Pt is c/c/c
Bp 150/80mmhg
PR 67bpm
Cvs S1 S2+
RS BAE+
CNS NFD
P/A soft non tender

[27/05/23, 10:22:40 AM] ~ Dr.ramyareddypebbeti🩺: 3.Op no:20230544118
56/F
C/o pedal edema since 2 weeks 
 B/L knee Pain since 1 month 
C/o polyuria 
No h/o decreased urine output,burning micturition
No h/o chest pain ,SoB,palpitations 

K/c/o type 2 DM since 10years (on regular medication GLIMI M2 Po/BD 

O/E :
Knee joint examination:
Crepitus + in B/L knees 
Joint line tenderness + b/L 
Restriction of movements +
SLRT: right knee- 90degrees
           Left knee -80 degrees 

Patient was advised for admission  for further evaluation but not willing for admission

[27/05/23, 10:23:33 AM] Rakesh Biswas Sir: Clinical images?

Check the group description box for the check list for your complete workflow around every patient and do accordingly
Let me know if you are unable to locate the checklist

[27/05/23, 10:24:08 AM] Rakesh Biswas Sir: Relieved on lifting?

[27/05/23, 10:24:33 AM] Rakesh Biswas Sir: Clinical images?

Check the group description box for the check list for your complete workflow around every patient and do accordingly
Let me know if you are unable to locate the checklist

[27/05/23, 10:24:39 AM] ~ Rajkumar Adepu: Yes sir

[27/05/23, 10:24:51 AM] Rakesh Biswas Sir: Clinical images?

Check the group description box for the check list for your complete workflow around every patient and do accordingly
Let me know if you are unable to locate the checklist

[27/05/23, 10:25:05 AM] Rakesh Biswas Sir: What does that mean?

[27/05/23, 10:45:41 AM] ~ Rajkumar Adepu: 4
Op no 20230544125
48 F
Daily routine
Farmer by occupation
Wakes up at 7 am in the morning and completes her household chores by 9 am and eats her breakfast and goes to work and eats lunch at 1 pm and continues to work and comes back home by 5pm will do house work and prepare dinner and eat by 8pm and goes back to sleep
Pt came with 
C/o chest pain rt sided chest pain since 2 days
H/o tingling sensation +
C/o loss of appetite
K/c/o DM 2 since 6 years on tab glimi 3mg + metformin 1000mg
K/c/o HTN since 2 weeks on tab met xl 25mg
CVS S1 S2+
RS BAE
CNS NFD
P/A soft non tender
Pt advised for admission but want to visit again

[27/05/23, 10:48:24 AM] ~ Dr.ramyareddypebbeti🩺: 5.Op no:20230543172
55/M
C/o tingling sensation of both upper and lower limb since 1 month 
Perioral tingling + since 3 weeks
Associated with generalised weakness 
No h/o polyuria ,polyphagia and polydypsia 
No h/o burning micturition,nocturia
N/k/c/o DM,HTN,TB, Thyroid,epilepsy and asthma   
O/E 
No pallor ,icterus ,clubbing ,lymphadenopathy and edema 

CVS- S1 S2 heard no murmurs
RS-BAE+ NVBS  
P/A- soft non tender 
CNS-NFND   
Daily routine- wakes up at 5am and goes for work(farming )eats breakfast at around 8am and  lunch at 1pm(rice and curry) and does household work in the evening and dinner at 8pm and sleeps at 9pm
daily routine is disturbed due to tingling sensation since 1 month 
Patient was advised admission but want to come back on Monday for admission

[27/05/23, 10:54:04 AM] ~ Rajkumar Adepu: 6
Op no 20230544569
35/F
Pt came with c/o headache in both temporal region since 5-6 months
Headache everyday relieved on medication
Aggrevated by sunlight
Photophobia +
N/k/c/o htn,dm,  cad ,cva
Daily routine
7am wake up and does house work by 9am
9 has her breakfast 
9:30 goes for  work 
At 1 she has her lunch
Returns to home at 5pm
5-6 takes rest 
6-8:30 House works
8:30 lunch
10pm goes to sleep
No change in daily routine 
O/E 
Cvs- s1s2 heard
RS - BAE + , NVBS heard
CNS- NFND
P/A - soft, non tender

[27/05/23, 11:04:06 AM] ~ Dr.ramyareddypebbeti🩺: 7.Op no:20230544599
23/F
 23 yr old female ,nursing student,came to opd with c/o  b/L lower limb swelling up to ankle  since 1 week (on and off)
Insidious in onset ,gradually progressive ,aggravating on sitting for prolonged time and relieving on walking for some distance 
No h/o burning micturition,frothy urine ,decreased urine output 
No h/o chest pain,sob , palpitations 

N/k/c/o DM,HTN,TB, Thyroid,epilepsy and asthma   
O/E 
pallor+
Noicterus ,clubbing ,lymphadenopathy and edema 

CVS- S1 S2 heard no murmurs
RS-BAE+ NVBS  
P/A- soft non tender 
CNS-NFND   

Patient was advised for admission but not willing

[27/05/23, 11:12:28 AM] ~ Rajkumar Adepu: 8
Op no 20230544725
55 M
Driver by occupation
H/o  head trauma in 2007 in RTA not associated with loc , vomitings
Currently presented with c/o giddiness since 3months relieved on lying in supine position
H/o alcohol consumption 180ml/day (whiskey)
Pt is c/c/c
Afebrile on touch 
Bp 130/90 mmHg
CVS S1 S2+
RS BAE+
P/A soft and non tender 
CNS
 cerebellum 
Nystagmus absent
Finger nose test normal
Dix hallpike negative 
Pt advised for admission but wants to come back on Thursday

[27/05/23, 11:51:30 AM] ~ Rajkumar Adepu: 9
Op no 20210322768
47 M
Works in PAN shop
Lifts weights 
C/o pain in both shoulders since 6 months
No restriction of movement
Pain increased on activity, lifting weights
N/k/c/o HTN DM CVA CAD TB
O/e 
Pt is c/c/c
Shoulder examination 
Pain on abduction of >90 degree on both sides
Pain on extension+
Cvs S1 S2+
RS BAE
CNS NFD
P/A soft and non tender
Rx
Advised physiotherapy

[27/05/23, 12:03:20 PM] ~ Rajkumar Adepu: 10
Op no 20210412828
Works as shopkeeper
Daily routine
6am wakes up
8am Breakfast
9 goes to work 
12pm lunch 
4pm back to home
Does house work and takes rest
8pm dinner 
9pm sleep

C/o headache in parietal , frontal region
Since 1 yr on and off weekly once 
Aggrevated on sunlight and travel relieved on taking medication 
Photophobia +
Nausea+
N/k/c/o HTN DM CVA CAD TB
Pt is c/c/c
Bp 90/60 mmHg
Pr 80bpm
Cvs S1 S2+
RS BAE+
CNS NFD
P/A soft and non tender

[27/05/23, 12:23:53 PM] ~ Rajkumar Adepu: 11
Op no 20230545154
Pt came with c/o left side of chest and back pain since 15 days pricking type 
K/c/o herpes zoster since 1 month
H/o fever for 5 day high grade Associated with chills and resolved
N/k/c/o HTN DM CVA CAD TB
O/e
Pricking type of pain along the dermatomes on front and back of chest
CVS S1 S2+
CNS NFD
RS BAE+
P/A soft and non tender

[27/05/23, 12:24:44 PM] ~ Rajkumar Adepu: Pt advised for admission but not willing

[27/05/23, 12:34:57 PM] ~ Dr.ramyareddypebbeti🩺: 12.
Op no 20210122502
Follow up case of DVT since April 10/23
C/o pain and swelling of left leg
(On tab .acetrom 2mg)
On examination of lower limb tenderness absent at calf region 
Swelling + (pitting type)

N/k/c/o HTN DM CVA CAD TB
H/o 2 SDP transfusion i/v/o thrombocytopenia 

Pt is c/c/c
Bp 100/80mmHg
Pr :72bpm
Cvs S1 S2+
RS BAE+
CNS NFD
P/A soft and non tender
Pt advised for admission but not willing

[27/05/23, 12:35:57 PM] ~ Rajkumar Adepu: 13
Op no 20230545164
48M
Pt came for general health check up 
C/o pain of left upper limb dragging type below elbow
N/k/c/o HTN DM CVA CAD TB
Pt is c/c/c
Bp 140/100 mmHg 
CVS S1 S2+
RS BAE+
CNS NFD
P/A soft and non tender 
Pt advised for admission but not willing

[27/05/23, 1:45:06 PM] Rakesh Biswas Sir: How to prepare a case report :

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

[27/05/23, 3:13:03 PM] ~ Dr.ramyareddypebbeti🩺: 14.
Op no 20230545673
C/o  right neck pain since 5days ,insidious in onset ,gradually progressive,dragging type ,radiating to both the shoulders 
No h/o restriction of neck movements 
C/o pain in left hand and swelling of hand since yesterday 
No h/o trauma to the hand 
H/o cough since 10 days ,non productive,no h/o wheeze ,chest pain ,Sob

K/c/o hypothyroidism since 3 months (on thyronorm 50mcg)
N/k/c/o HTN DM CVA CAD TB


Pt is c/c/c
Bp 100/80mmHg
Pr :72bpm
Cvs S1 S2+
RS BAE+
CNS NFD
P/A soft and non tender
Pt advised for admission but not willing

[27/05/23, 4:06:48 PM] Rakesh Biswas Sir: Age? Gender?

[27/05/23, 4:07:27 PM] ~ Dr.ramyareddypebbeti🩺: 45/M

Comments

Popular posts from this blog

My experiences with general cellular and neural cellular pathology in a case based blended learning ecosystem's CBBLE

Collation of OPD Data for PLA book draft.

57 year old male with CKD