PLA BOOK PROJECT DRAFT OPD week-1
Week -1
29th April 2023,Saturday
[29/04/23, 3:22:48 PM] ~ Sowmya Rani: A patient of 35 yrs male resident of chityala work as driver came to opd
Cc:
SOB-3 days
Fever- 3 days
Cough-2 days
Cold-2 days
HOPreI: Patient apparently asymptomatic 3 days back then he had
SOB - insidious onset, gradually progressive, relieved by taking medicine advised from medical store, Grade 2, no Orthopnea and PND,wheezing during sleeping
FEVER- sudden in onset,gradually progressive, high grade during morning with high spikes, relieved evening &raise of temperature during night with chills and rigors
COUGH- sudden in onset, gradually progressive with sputum in yellow color, no foul smell,
COLD- sudden in onset, gradually progressive
H/o loss of weight of 15 kgs
H/o of Sweatings
H/o of regurgitation of food,
No H/ o of loose tools, nausea, burning micturition
HOPI:
NO H/O HTN,DM,EPILEPSY, THYROID, TB,ASTHMA
Family history: not significant
PERSONAL HISTORY:
Dietary-mixed
Bowel &Bladder- regular
Appetite- normal
Loss of weight-15 kgs
sleep adequate
Food allergies-absent
Alcohol-3-4days weekly, 250 ml / day
PROVISIONAL DIAGNOSIS:
ASTHMA, Bronchospasm
General examination:conscious, coherent and cooperative
No pallor, Icterus, Cyanosis, Clubbing, lymphedenopathy, pedal edema
Vitals:
PR - 78 beats /min
RR- 24counts/ min
[29/04/23, 4:04:42 PM] ~ Bhuvana phanindra Sharma: 29/4/23; Saturday
OPD cases
Morning:
1)35/M- SoB,cough,cold and fever-admitted
2)45/F- fever since two days
3)32/M- chest pain -burning sensation with belchings,ecg-nsr
4)55/M f/c/o histoid Hansen with enl.
C/o abdominal distension since 20days.
Admission advised-pt wants to come after 2 days.
5)22/M-anemia with hemarroids
Advised admission-bed charges issue-admitted
6)60/f weekneds of right upper and lower limb.with deviation of mouth to left since 1week
K/c/o htn since 7years
Advised admission-not willing,want to get admitted on Monday.
7)50/F-headache since 1 year
Advised admission.
8)55/M-k/c/o DmT2 since 4 years
C/o abdominal distension with retrosternal pain.
9)30/M-tingling sensation over face since 1week
Advised admission -wants to get admitted on Monday
10)28/f- c/o headache since 1 year.
11)40/f- b/l pedal edema since 1year, SoB since 1year, pallor+
Advised admission -no attenders,wants to get admitted later.
12)50/f- giddiness since 1 year
Advised admission -admitted
Afternoon:
1)53/f- polyarthritis since 8months with anemia
Advised admission -wants to get admitted on Monday.
2) 65/M- weakness of right upper limb and lower limb since 1 day ,
MRI -hypertensive bleed
No patient,reports brought by attender.
3)58/m- headache since 6days fever since 6days
4)30/f- headache since 1day,
Helper in hostel
5)50/M- pain in epigastrium since 2days with dyspepsia, ecg-nsr
6) /F- b/lpedal edema, SoB
Cue-proteinuria+
2D echo- dilated chambers.
Advised admission -wants to get admitted on Monday.
7)31/M- chest pain since 1month
Adv-ecg-nsr
8)50/F- low back ache.
9)49/M- denovo DM, explained diabetic diet
10)45/F- fever with chills, burning micturition.
Advised admission -wants to get admitted later
11)45/F- DM T2 since 20years, uncontrolled;fbs-550,plbs-447,Hba1c-7.5 , on Inj.MIXTARD 15-10U.
Advised admission -not willing (not prepared).
12)50/M-T2 DM since 2 years (hba1c-7.5) advised admission - not prepared for admission.
13)60/M - k/c/o T2DM since 18yrs
Fbs-580, plbs-732, HbA1c-8.1
Admitted.
[29/04/23, 4:25:33 PM] Rakesh Biswas Sir: Thanks.
So we had 25 patients in opd today and three admissions?
@As OPD Pg incharge please get our non duty interns from other units to share the case report and PaJR links to the new ward admissions asap while the duty interns can do it for the Casualty patients
[29/04/23, 4:29:02 PM] Rakesh Biswas Sir: Well done @👏👏
Please share his chest X-ray asap @
SpO2?
What about the case reports by the 2019 posted with us?
[29/04/23, 4:30:32 PM] Rakesh Biswas Sir: Please share in how many of these 23 patients who didn't get admitted, we ordered tests and which tests were ordered
[29/04/23, 4:33:24 PM] Rakesh Biswas Sir: Please mention your batch year and your online portfolio link that you can find in our dashboard here 👇
https://medicinedepartment.blogspot.com/2022/02/?m=0
[29/04/23, 4:33:44 PM] ~ Kotha Kavya: Ok sir
[29/04/23, 4:36:20 PM] Rakesh Biswas Sir: Where's the CNS examination and fundoscopy finding that is essential for any patient with headache?
[29/04/23, 4:38:06 PM] Rakesh Biswas Sir: 👆Which patient is yours in this list here?
[29/04/23, 4:41:43 PM] Rakesh Biswas Sir: This patient is the first one in the list of opd patients prepared today by ?
[29/04/23, 4:41:46 PM] ~ Kotha Kavya: Morning adminission no:7 sir
A 50/F-headache since 1year advised admission.
[29/04/23, 4:42:21 PM] Rakesh Biswas Sir: You reduced her age by 10 years?
[29/04/23, 4:43:28 PM] ~ Sowmya Rani: Yes sir
[29/04/23, 4:44:29 PM] ~ Kotha Kavya: This is K.KAVYA ROLL.NO:167
2019 batch.
A 50yrs old female who is a resident of suryapet who is a daily labourer came with
CHIEF COMPLAINTS OF :
Headache since 1year
Giddiness since yesterday.
HOPI :
Patient was apparently asymptomatic 1 yr back and then she had headache with increased severity since yesterday which is incidious in onset and gradually progressive
which is throbbing type and no associating or relieving factors. And associated with giddiness since yesterday without loss of counciousness.
No h/o fever , vomitings, nausea
No h/o weakness
No h/o body pains, shortness of breath, burning micturition
No h/o eye pains.
PAST HISTORY:
H/o hysterectomy 20yrs back
N/k/c/o Diabetes, HTN, asthma, CVA, epilepsy,CAD.
TREATMENT HISTORY:
Using medications for headache since 1year.
FAMILY HISTORY: Not significant.
PERSONAL HISTORY:
Diet : mixed
Sleep : adequate
Bowel and bladder : regular
Appetite: normal
Addictions: nil
Allergies: nil
GENERAL EXAMINATION:
Patient was conscious coherent and cooperative
Moderately built and nourished.
VITALS: BP:90/60 mmhg
PR:74bpm
RR:18cpm
No pallor,icterus, clubbing,cyanosis, lymphadenopathy and pedal edema.
[29/04/23, 4:44:58 PM] ~ Kotha Kavya: Sorry sir. I kept the changes now
[29/04/23, 4:47:21 PM] Lohith Pg Gm : interns from other units, will be doing the PaJRs for the 4 admitted cases sir
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