PLA BOOK PROJECT DRAFT OPD(August 14-August 19)
14th August 2023-19th August 2023
14th August 2023,Monday
[14/08/23, 9:49:03 AM] ~ Rahul: Ip no: 20210209964
A 38 year old female patient came with
C/o of swelling in the neck, dysphagia,sweating, weightloss, fearfullness, generalized weakness,
K/c/o hashimoto thyroiditis
No c/o of orthopnea, pnd, sob
No c/o of chestapain palpitations
O/E pt is c/c/c
Afebrile
PR - 60bpm
RR - 16cpm
Bp - 110/70mmHg
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy
Cvs - S1S2 +, no murmurs
RS - BAE+, NVBS
Cns - NFND
Per abdomen -soft and non tender
Advice
Symptomatic treatment
Daily routine-
SHe is farming
Patient is a paddy field farmer, She wakes up by 5:30 in the morning, drinks tea, she will do household work (cleaning house) and goes to work by 8:00 am.
SHe does farming till 12-12:30 pm and has lunch. He rests for 45mins - 1 hour and again gets back to work. SHe will reach home by 5:00pm and watches television and goes for a walk with his friends till 8:00pm, comes back and has dinner and sleeps by 10:00pm
The above mentio Ined complains haven’t effected her daily routine yet.
[14/08/23, 10:10:32 AM] ~ Rahul: Op no: 20230821318
A 70 year old male came with c/o discharge from left big toe since 10days burning sensation of mouth since 4mnths associated with nausea and blackish discoloration of palms soles and tongue since 4mnths after taking anticancer drugs
K/c/o dm-2 , htn since 13 Years no h/o tingling sensation, constipation, burning micturition, loss of sensation
On Examination -
Patient is conscious, coherent, cooperative
Temp: afebrile
BP: 80/50 mmHg
Pr: 98bpm
No signs of pallor, icterus, cyanosis, clubbing and lymphadenopathy.
CVS: S1,S2 heard, No murmurs
RS : bae+ , NVBS heard
P/a : soft,non tender,bowel sounds+
CNS : NFAD
Daily routine-
Patient wakes up at 7 and freshens up and he will eat breakfast by 8 am mostly eats idilli /dosa . Then spends her time by taking rest at 1 pm he will take lunch , then takes nap till 5 pm after waking up she drinks his tea and then spends her time talking with her neighbours , then by 9 pm eats her dinner and goes to sleep by 10:00 pm .
His daily routine is not affected by the above mentioned complains
Advice:
Patient managed conservatively with medication
[14/08/23, 10:22:40 AM] ~ Rahul: Op no. 20210110755
A 47yr old female came to OPD with C/o neck pain since 6 months, radiating to right shoulder
no h/0 fever , chestpain, cough , palpitations, burning micturition,
N/k/c/o , HTN, epilepsy, thyroid disorders, CAD,CVD, asthma.
On Examination-
Patient is conscious, coherent, cooperative
Temp: afebrile
Pr: 87bpm
Bp: 120/70mm Hg
Rr: 22 cpm
No signs of pallor , icterus, cyanosis,clubbing and lymphadenopathy.
CVS: S1 S2 heard, No murmurs
RS: bae+, NVBS heard
P/A: soft, non tender, bowels sounds+
CNS - NFND
Daily routine-
The patient is a homemaker. She wakes up at 6:30 am, freshens up, nd does her household work by 8:00 and after that she has her breakfast at 8:30am. After that she watches tv amd spends time with family. She has her lunch at 2 pm and sleeps till 4:00 pm. If there's any requirement regarding groceries she goes to marketplace after 5 and has her dinner by 8:00 pm. She goes to bed by 9:00 pm. Her daily activities don't get disturbed because of the complaints.
Advice :
Patient is managed conservatively with medication
[14/08/23, 11:06:48 AM] ~ Rahul: Op no. 20230821783
A 66 yr old female came to OPD with cheif c/o pain in neck region since 2months and movements are restricted . Pain is not radiating and burning sensation , chest pain since 4mnths
No h/o polyuria , polydepsia and nocturnia
She is a k/c/o diabetes since 2mnths she was not on medication
N/k/c/o HTN,asthma,TB,CAD,CVA, Epilepsy
On Examination-
Patient is conscious, coherent, cooperative
Temp: afebrile
Pr: 88 bpm
Bp: 130/90mm Hg
Rr - 18 cpm
No signs of pallor , icterus, cyanosis,clubbing and lymphadenopathy.
Daily routine-
she is a home maker wakes up at 7am cooks breakfast for her children and sends them to school takes her lunch at 2pm and watches tv for 1 to 2 hrs then agian takes tea at 5pm and cooks dinner and eat chapatis at 8 pm and sleeps at 10pm
Advice:
Patient is managed conservatively
[14/08/23, 11:35:31 AM] ~ Rahul: Op no- 20230821808
31 year old male came to opd c/o chest pain since 6months Intermittent, dragging type of pain , Non radiating type
H/o Palpitations sweating
Gladness
No nausea , No vomiting
No fever, Cold, cough...
No history of cold, cough, vomiting, loose stools.
Not a k/c/o DM ,CAD,CVA,seizures,HTN, TB,Asthma
On Examination-
Patient is conscious, coherent, cooperative
Temp: afebrile
Pr: 72bpm
Bp: 120/70 mm Hg
Rr - 20cpm
No signs of pallor,icterus, cyanosis,clubbing and lymphadenopathy.
Cvs: S1 S2 heard,No murmurs
Rs: blae+, NVBS heard
P/a: soft, non tender, bowels sounds+
CNS - NFAD
Daily routine-
Patient is a house maker
he wakes up by 6:30 in the morning freshen up and has his breakfast by 7:30am and he will had his lunch by 12:30pm Lunch include( rice with daal or vegetable curries) and has dinner(rice with daal) by 8pm and goes to bed by 10pm.
His daily activities are not disturbed
Advice:
Patient managed conservatively with medication
[14/08/23, 12:19:47 PM] ~ Rahul: 1. OP no -20230822371
70year old man C/O headache since 20 days
There were no aggravating or relieving factors.
Not a k/c/o -HTN,CAD,CVA, asthma, epilepsy
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 80 bpm
Bp: 120/80 mm Hg
Rr: 20 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no added sounds
Rs:-BAE+, NVBS +
P/a: - soft, non tender
CNS: - NFD
Daily routine- he wakes up by 7:30 in the morning, drinks tea, helps his wife with household work (cleaning house) and goes to work by 8:00 am.
He does fishing till 12-12:30 pm and has lunch. He rests for 45mins - 1 hour and again gets back to work. He will reach home by 5:00pm and watches television and goes for a walk with his friends till 8:00pm, comes back and has dinner and sleeps by 10:00pm
The above mentioned complains haven’t effected his daily routine yet.
[14/08/23, 7:16:20 PM] Rakesh Biswas Sir: She's not on thyroxine?
[14/08/23, 7:16:44 PM] Rakesh Biswas Sir: Which anticancer drugs for what cancer?
[14/08/23, 7:18:54 PM] Rakesh Biswas Sir: What medications is she on for her diabetes?
15th August 2023,Tuesday
One of the things we tried to emphasize in the 2017 internship completion online portfolio assessments is the intern logging his her work daily in a manner to leave regular online traces to their work, which can be verified with the date of logging even here in the whatsapp groups.
For example you can log all your offline and online work around your particular patient into her case report that will automatically also show the date and time of your logged inputs in the PaJR groups.
If we need to evaluate your performance at a later date during internship completion extension decision making, you would have sufficiently logged evidence of your work on this date.
Pĺease share this with other 2018 interns and please ask them to seek any clarifications here in the main group
16th August 2023,Wednesday
[16/08/23, 10:16:26 AM] ~ Madugula Vineeth: Op no. 20210512069
A 57 yr old male came to OPD for general checkup
K/c/o HTN since 10yrs on Tab TELMA 40mg PO/OD
C/o burning micrurition since 3 months normal color ,no frothing,non foul smelling
N/k/c/o DM,TB,CVA,CAD
On Examination-
Patient is conscious, coherent, cooperative
Temp: afebrile
Pr: 90 bpm
Bp: 140/80 mm Hg
Rr - 18cpm
No signs of pallor , icterus, cyanosis,clubbing and lymphadenopathy.
Daily routine-
The patient was a farmer before now he is not doing any work. The patient wakes up by 5 am goes for a walk 1hr after that he freshens up and takes his breakfast at 8:00am. Then he takes his lunch at 2pm after that he takes a short nap.He drinks tea around 4.00pm. he takes dinner at around 8 pm and goes to sleep at 9.30pm.
His daily activities are not disturbed
[16/08/23, 10:27:52 AM] Rakesh Biswas Sir: What is general check up?
Typical terminological biomarkers for "overdiagnosis and overtreatment" are general check up, whole body check up etc? @919000166698 @919604701505
[16/08/23, 10:48:28 AM] ~ Rahul: Would that be LIONC (https://loinc.org/) or SNOMED (https://browser.ihtsdotools.org/?perspective=full&conceptId1=102576009&edition=MAIN/2023-07-31&release=&languages=en)?
[16/08/23, 11:16:53 AM] Prasanna Karnati 18: Op no 20230824509
59 yr old man with c/o chest pain since 3 days
Left sided aching type of chest pain at 3rd&5th ICS .intermittent and non radiating
No aggravating and relieving factors
No c/o sob,orthopnea,pnp
No c/o sweating,palpitations
Occasional fry cough since 3 days
No c/o loose stools,nausea,vomitings
No c/o fever,cold
No c/o burning micturition ,increased urine output
K/c/o HTN since 5 years on T.Telma 40mg PO/OD
DM since 5 years on T.Metformin 500mg/OD
H/o Renal calculi surgery 3 years ago
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 100 bpm
Bp: 130/70 mm Hg
Rr: 20 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no added sounds
Rs:-BAE+, NVBS +
P/a: - soft, non tender
CNS: - NFD
Daily routine
Patient wakes up at 6 am in the morning , eats rice at 8 am , then goes to work (daily labourer)
. He eats lunch at 2 pm ,takes some rest , eats rice for dinner at 8pm and goes to sleep.
His daily activities are not disturbed
[16/08/23, 11:17:50 AM] ~ Madugula Vineeth: Op no. 202104108020
A 62 yr old male came to OPD with c/o Shortness of breath (grade 3) since 5 days
No orthopnea,PND
C/o epigastric pain,non radiating , continuous relieved after sitting
No c/o fever,cough,cold
C/o b/L pedal edema pitting type extending upto knee since 1 week
C/o decreased urine output since 2 months
No c/o burning micrurition
N/k/c/o HTN,DM,TB,CVA,CAD
On Examination-
Patient is conscious, coherent, cooperative
Temp: afebrile
Pr: 84 bpm
Bp: 120/80 mm Hg
Rr - 17cpm
No signs of pallor , icterus, cyanosis,clubbing and lymphadenopathy.
Daily routine-
The patient is a farmer . The patient wakes up by 5 am goes to farm comes back at 7 after that he freshens up and takes his breakfast at 8:00am.goes to work.Then he takes his lunch at 2pm. he takes dinner at around 8 pm and goes to sleep at 9.30pm.
His daily activities are not disturbed
[16/08/23, 11:18:01 AM] Prasanna Karnati 18: Op no 20210420206
57yr old man with c/o generalised body swelling since 3 days.
C/o abdomen bloating sensation since 3 days
Occasional high grade fevers since 3 days not associated with chills and rigors . Fever is intermittent,aggravated at night ,relieved by medication.
No c/o decreased or increased urine output.
H/o similar complaints 4 years back .
Used tab.dytor plus 20mg
H/o jaundice 20 years back,used herbal medication.
C/o loss of appetite
No c/o loose stools,vomitings,constipation
K/o asthma since 20 years ,on inhaler salbutamol 100mcg
N/k/c/o DM ,HTN ,THYROID DISORDER ,CAD ,CVA
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 64 bpm
Bp: 100/60 mm Hg
Rr: 20 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no added sounds
Rs:-BAE+, NVBS +
P/a: - tenderness present on deep palpation in right and left iliac fossa
CNS: - NFD
Daily routine
Patient wakes up at 6 am in the morning , eats rice at 8 am , then goes to work (daily labourer)
. He eats lunch at 2 pm ,takes some rest , eats rice for dinner at 8pm and goes to sleep.His daily activities are not disturbed
[16/08/23, 11:19:01 AM] Rakesh Biswas Sir: I don't think they are standard formal terminology but informal hidden curriculum of medicalized corruption! 🙂🙏
[16/08/23, 11:22:00 AM] Prasanna Karnati 18: Op no 20230816924
21 yr old female with c/o loose stools since today
C/o cough and cold since 1 week.
2 episodes of loose stools,watery,non foul smelling,non blood tinged,accompanied with loss of appetite,nausea
c/o mild cough since 2 weeks,white expectoration,non blood stained,accompanied with cold.
Not associated with runny nose,sneezing
c/o fever since 1 week high grade associates with chills and rigors,continous.
No diurnal variation,no aggravating and relieving factors.
Accompanied with generalised weakness . Used t.Monocef for 8 days.Now fever subsided .
C/o belching,nausea
No c/o burning micturition
No c/o abdominal pain
Dx- Viral pyrexia(resolved)
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 80 bpm
Bp: 110/70 mm Hg
Rr: 20 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no added sounds
Rs:-BAE+, NVBS +
P/a: - soft, non tender
CNS: - NFD
Daily routine
Pt is a student ,wakes up at 7am,has breakfast and go to college and eats lunch at 1pm ,come back to home by 6pm. Freshens up and has dinner at 8pm. Sleeps by 10pm.
Daily routine is disturbed
[16/08/23, 11:24:18 AM] ~ Rahul: lol, got it!
What would be the diagnosis terminology equivalent of the standard treatment workflows of India (https://main.icmr.nic.in/sites/default/files/Books/STW_Manual_v1.pdf)?
[16/08/23, 11:32:33 AM] Rakesh Biswas Sir: Will share something prepared by NMC for our curriculum that we have processed here in the second last link contained in the link here👇
http://userdrivenhealthcare.blogspot.com/2022/12/?m=0
[16/08/23, 11:33:01 AM] ~ Madugula Vineeth: Op no- 20230824518
A 18yr old female came to OPD with c/o headache since 3 days
Headache is diffuse,
Photophobia+, pricking type of pain,non radiating ,head heaviness
H/o cold 3 days ago
H/o cough -dry non productive
C/o fever-high grade associated with chills and rigor ,no diurnal variation continuous,no aggravating and relieving factors accompanied by generalised myalgia,prickling sensation in both palms
No H/o dizziness,vomiting ,neck pain
Not a k/c/o DM,HTN,CAD,CVA,seizures,thyroid disorders, TB,Asthma
On Examination-
Patient is conscious, coherent, cooperative
Temp: afebrile
Pr: 80bpm
Bp: 110/70 mm Hg
Rr - 16 cpm
No signs of pallor , icterus, cyanosis,clubbing and lymphadenopathy.
CVS: S1 S2 heard,No murmurs
RS: bae+, NVBS heard
P/A: soft, non tender, bowels sounds+
CNS - NFAD
Daily routine-
The patient is a nursing student.she stays in hostel. The patient wakes up by 7am freshens up and and takes her breakfast at 8:00am and goes to work. Then she takes her lunch break at 2pm and then she takes rest .she takes snacks at 5pm whatever the snacks are provided by the mess. she takes dinner at around 8 pm and goes to sleep at 10 pm.
Her daily activities are disturbed.
[16/08/23, 11:38:04 AM] ~ Rahul: oh wow!
https://medicinedepartment.blogspot.com/2022/10/nmc-competency-based-topic-and-subtopic.html?m=0
Is there a more comprehensive list by NMC? Or this covers all?
[16/08/23, 11:39:46 AM] Rakesh Biswas Sir: That's the third last link. I should think it does cover must know areas and surely we can never agree upon must know, nice to know etc!
[16/08/23, 11:59:35 AM] Prasanna Karnati 18: Op no 20210210988
67 yr old woman with c/o burning micturition since 1 year,occasionally dark coloured.
C/o back pain since 1 week . Left sided,dragging type of pain ,continuous,radiating to foot.
Not associated with tingling sensation
H/o similar complaints in the past.relieved with medication
C/o neck pain since 10 days localised at cervical region,dragging type of pain,intermittent,radiating to occipital region.
Restriction of movements present.No aggravating and relieving factors.
No c/o chest pain,cough,cold,fever.
Occasional sob (grade 2)NYHA
No c/o sweating,palpitations,orthopnea
Occasional complaint at left hypochondriac region aggravated on having sour foods,accompanied with belching,flatus,acid reflux
No c/o increased or decreased urine output.
No c/o loose stools,nausea,vomitings.
NOC/o loss of appetite,weight loss,insomnia.
K/c/o HTN since 4 years,on same medication T.Atenolol 25mg
N/k/c/o dm thyroid ,CAD,CVA
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 80 bpm
Bp: 170/90 mm Hg
Rr: 20 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no added sounds
Rs:-BAE+, NVBS +
P/a: - soft, non tender
CNS: - NFD
Daily routine
Patent is a home maker.She wakes at 7am. Has breakfast at 8am.Takes a nap. Has Lunch at noon. Sleeps again .She drinks tea at 5pm.She takes dinner at 8pm.Slees by 9pm
Daily activities are not disturbed
[16/08/23, 2:25:32 PM] Prasanna Karnati 18: Op no 20210421049
40yr old male with c/o generalised weakness since 1 week
c/o tingling and numbness of both upper and lower limbs since 1 week
c/o fever since 1 week
c/o chest pain since week,aggravated on alcohol intake and spicy foods
No vomitings,loose stools
No burning micturition
No sob/palpitations/pnd/orthopnea
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 80 bpm
Bp: 110/90 mm Hg
Rr: 16cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no added sounds
Rs:-BAE+, NVBS +
P/a: - soft, non tender
CNS: - NFD
Daily routine
Patent is a daily wage labourer.He wakes up at 6am. Has breakfast at 8am.Goes to work.Has Lunch at noon. Resumes his work .He drinks tea at 5pm.He takes dinner at 8pm.Slees by 9pm
Daily activities are disturbed
[16/08/23, 3:01:42 PM] ~ Akshi: Op no-20210109546
A 23 year old female came to opd with c/o headache since 4days,unilateral right sided headache which is of throbbing type,intermittent,radiating from frontal to neck and occipital region accompanied with nausea ,giddiness,postural variations present aggrevated on changing positions .no h/o photophobia ,phonophobia
C/o cold since 5days, runny nose and mild sneezing
Cough -productive(white sputum)Non foul smelling,non blood tinged,aggrevated at night ,accompanied with sob grade 2
C/o fever ,generalised weakness and myalgia
N/K/C/O HTN ,DM CAD ,CVD, Asthma ,TB
On examination:
Patient is conscious ,coherent and cooperative
Pallor +
No signs of icterus ,cyanosis,clubbing,lymphadenopathy
Bp:90/60mm hg
Pulse : 120 bpm
RR-16cpm
Cvs-s1s2 heard no added sounds
RS:BAE + ,NVBS + ,
P/A :soft,nontender.
CNS -NFD
Daily routine:
She works as staff nurse who wakes up at 4am and goes to duty at 7am and has her breakfast at 9am.she has her lunch at 2pm and goes back to work at 3pm .she comes back home at 8pm finishes her dinner by 9pm and
sleeps by 11pm.
Daily activities are not disturbed
[16/08/23, 4:12:46 PM] ~ Madugula Vineeth: Op no.20230824527
A 27 yr old male came to OPD with c/o abdominal pain since today morning insidious in onset gradually progressive in nature intermittent, dragging type
H/o similar complaints 3 days back which relieved on taking pills
Not a k/c/o DM,HTN,CAD,CVA,seizures,thyroid disorders, TB,Asthma
On Examination-
Patient is conscious, coherent, cooperative
Temp: afebrile
Pr: 90bpm
Bp: 110/70 mm Hg
Rr - 16 cpm
No signs of pallor , icterus, cyanosis,clubbing and lymphadenopathy.
Daily routine-
The patient is a nursing student. The patient wakes up by 7am freshens up and and takes his breakfast at 8:00am and goes to work. Then he takes lunch break at 2pm and then he takes rest .he takes snacks at 5pm whatever the snacks are provided by the mess. he takes dinner at around 8 pm and goes to sleep at 11pm.
His daily activities are not disturbed
17th August 2023,Thursday
https://chat.whatsapp.com/GQ1UUeFMFsf86ifg61NjtL
[8/17, 7:57 PM] Metapsychist Number 1 Kims 2015: History or case report?
[8/17, 7:59 PM] Metapsychist Number 1 Kims 2015: What are the complaints?
[8/17, 8:03 PM] Rakesh Biswas: Patient was admitted and discharged in KIMS NKP during December 2018 with lower urinary tract symptoms and open angle glaucoma (as in the discharge summary and other recent report collage in the DP)
His current complaints appear to be difficulty in swallowing and that has brought a lot of focus on his thyroid nodule and he may be coming over soon from 2000 kms for an excision biopsy
18th August 2023,Friday
[18/08/23, 9:34:29 AM] Rakesh Biswas Sir: Can @918309113758 guided by @919000166698 take over this activity till your practical exams are over? Yesterday appears to have been a project holiday with nil data captured from OPD?
[18/08/23, 9:49:10 AM] Kshitij Sharma: Taking it over sir!
[18/08/23, 10:53:13 AM] ~ Nischal cyril: Op no -20230827762
65year old man a k/c/o DM2 since 2 years came to the OPD with complains of chest pain.
Patient complains of chest pain radiating to left hand since 2 weeks
No Weight loss, no SOB, no fever, no evening rise in temp
Loss of appetite +
K/C/O- DM type II ( on T. Glycomet gp1)
K/C/O- Pulmonary Koch’s (on ATT since 1 month)
Not a k/c/o -HTN,CAD,CVA, thyroid problems, asthma, epilepsy
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 72 bpm
Bp: 120/80 mm Hg
Rr - 18 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no murmurs
Rs:- decreased air entry on right side.
P/a: - soft, non tender
CNS: - NFD
Daily routine-
Patient used to work as a cattle farmer (raising cows and buffalos). Now he doesn’t work anymore. His son looks after them.
He wakes up by 6 in the morning, goes out to walk in his farm with his friends, comes back by 9 and has his breakfast. He stays at home resting and watching television.
Has his lunch by 1pm and takes a nap from 2-4pm.
He has his dinner again by 8pm and sleeps by 9:30-10pm.
The above mentioned complains have effected his daily routine.
[18/08/23, 11:22:51 AM] ~ Nischal cyril: Op no -20230826429
18yrs old woman came to OPD with complaints of stomach pain since 1 day.
Patient complains of abdominal pain at right flank pain; Sudden in onset; pricking type of pain; intermittent; non radiating
Aggravated on sitting position
Relieved on supine position.
No C/O of nausea, vomiting
C/O constipation since 2 days
Not a k/c/o- Dm, HTN, CAD, CVA, thyroid problems, asthma, epilepsy
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 70 bpm
Bp: 100/60 mm Hg
Rr: 16cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no murmurs
Rs:- BAE+
P/a: - soft, non tender
CNS: - NFD
Daily routine-
Patient is a BSC nursing student.
She wakes up daily by 7:00Am. Uses her mobile for a while and gets freshen up, has her breakfast and leave to college by 8:45am.
She attends classes till 12pm and has her lunch. Attends classes again till 4:00 pm and goes to home by 5:00pm.
Used mobile while resting and had her dinner by 9:00pm and sleeps by 10:00pm
The above mentioned complains have effected her daily routine.
[18/08/23, 12:10:15 PM] Aarthi 18: OP number: 20230827881
A 40 year old male came to opd with complaints of pain in right hypochondrium since 1 month, constipation since 1month,chest pain in left side since 10days
No complaints of fever cough loss of appetite vomitings palpitations orthopnea PND burning micturition loose stools
K/C/O CAD PTCA 1year back
K/C/O DM and HTN since 6years and on medication
N/K/C/O ASTHMA TB EPILEPSY CVD
On Examination:
Patient is conscious,coherent,cooperative
No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy
Temperature: Afebrile
PR:82bpm
BP:110/70mmhg
CVS:S1 S2+,no murmurs
CNS:NAD
RS:BAE+ NVBS+
P/A:soft,non tender
Daily routine:
Occupation:
Patient wakes up at 5am and freshens up and has breakfast at 7am. Then he goes to work around 9am he works as a community medical officer who supervises at PHC and has his lunch by 1pm. Then he comes back home at around 4 pm and rests for an hour. Then walks for around 30 to 45 mins .Then he has dinner at around 7.30pm and goes to sleep around 9pm.
Advise:Fibre rich diet and adequate hydration and rest
[18/08/23, 12:32:43 PM] ~ Nischal cyril: Op no -20210402712
57years old man a K/C/O DM type II came to OPD with complaints of fever since 6 days.
Patient complains of fever since 6 days, low grade, associated with chills and rigors.
Cold present since 5 days
No cough.
No vomiting, no loose stools, no burning micturition, no headache.
Body ache +
Nausea +
K/C/O- DM type II since 3years
(on medication- patient doesn’t remember the name)
Not a k/c/o-, HTN, CAD, CVA, thyroid problems, asthma, epilepsy
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 82 bpm
Bp: 120/70 mm Hg
Rr: 16cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no murmurs
Rs:- BAE+
P/a: - soft, non tender
CNS: - NFD
Daily routine-
Patient is a cotton farmer.
He wakes up daily by 5:30am. Freshen up and goes to farming by 6:00 am.
He gets back to his home and has breakfast by 9:00am and rests till 1pm and has lunch.
After lunch he takes a nap of 1 hour and goes back to farm and does farming till 6:00 pm.
He has his dinner at 8:00pm and goes to sleep by 10:00pm.
The above mentioned complains have effected his daily routine.
[18/08/23, 12:54:04 PM] ~ Nischal cyril: Op no -20230827855
20years woman came to opd with chief complaints of fever since 3 days
Patient was apparently alright 3 days back, then she had c/o cold, runny nose, sore throat.
Complains of fever since 3 days, high grade, not associated with chills and rigors.
Aggravated at nights associated with nausea and vomiting
Cough- productive(white- yellowish)
Not associated with SOB, chest pain.
No c/o burning micturition
No c/o loose stools, vomiting
Not a k/c/o- DM, HTN, CAD, CVA, thyroid problems, asthma, epilepsy.
Examination: Patient is conscious, coherent, cooperative
Temp: Febrile on touch
Pr: 72 bpm
Bp: 110/80 mm Hg
Rr: 19cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy.
Cvs:-S1 S2 heard, no murmurs
Rs:- BAE+
P/a: - soft, non tender
CNS: - NFD
Daily routine-
Patient is a BSc MLT student.
She wakes up daily by 6:00am. Freshen up and studies for a while and has breakfast at 7:30am.
She goes to college by 9am.
Has lunch by 12 in the noon and gets back to class.
She comes back to her home by 4:30 in the evening.
Uses her mobile and sometimes goes out with her friends. Has her dinner by 8pm and goes to sleep by 10pm.
The above mentioned complaints have effected her daily routine.
[18/08/23, 3:25:53 PM] Rakesh Biswas Sir: In which hourly slots has her daily routine affected the most?
[18/08/23, 3:38:55 PM] Rakesh Biswas Sir: [8/18, 11:39 AM] +91 : Dear friends kindly join this poll. Please answer
[8/18, 12:03 PM] +91: In teaching schedule we are mentioning competency number.
One competency, we may take several classes. Objectives are derived from competency
We write objectives in ppt .
[8/18, 12:54 PM] +91: Yes there are many competencies which require more than one lecture
Agree
[8/18, 3:34 PM] Rakesh Biswas: While teaching, we click on this URL https://medicinedepartment.blogspot.com/2022/10/nmc-competency-based-topic-and-subtopic.html?m=0 and show them the numbers and as our teachings are patient centered, we often have to move from one code to the other.
Students appear to enjoy this and sometimes we start playing a memory game where students learn to even blurt out the codes depending on whatever topic the patient's comorbidities take us to. I must admit we don't indulge in this regularly.
[18/08/23, 5:19:37 PM] ~ Rahul: What a wonderful method.
Many schools and corporates have started using an app called Quizziz for such fun experiences.
https://quizizz.com/?lng=en
19th August 2023,Saturday
[19/08/23, 10:09:54 AM] ~ Tejaswini Kandhada: OP number: 20210106256
A 50 year old male came to opd with complaints of heart burn since 3 months and pedal edema since 6 months
No complaints of SOB , chest pain, palpitations
K/C/O DM since 15 yrs -using Tab. Glimiperide 2mg po/Bd ,Tab.Metformin 500 mg , Tab. Tenegliptin 20mg po/od
K/C/O HTN since 10 years and on medication (Tab. Amlodipine 10mg po/od)
N/K/C/O Asthma ,TB ,Epilepsy ,CVD
On Examination:
Patient is conscious,coherent,cooperative
No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy
Temperature: Afebrile
PR:89bpm
BP:120/70mmhg
CVS:S1 S2+,no murmurs
CNS:NAD
RS:BAE+ NVBS+
P/A:soft,non tender
Daily routine:
Occupation:
Patient wakes up at 6am and freshens up and has breakfast around 7:30 am. Then he goes to work at 9am he works as a weaver and has his lunch by 12pm,completes his work by 4pm in the evng and then he comes back home and rests for an hour and use his mobile for sometime .Then he has dinner at around 7.30pm ,walk for 20 mins and goes to sleep around 9pm.
His daily routine is not affected.
Advise:Fibre rich diet and adequate hydration and rest
[19/08/23, 10:20:06 AM] Rakesh Biswas Sir: Process this particular patient data into learning themes and demonstrate it's effect on patients illness outcomes
Begin identifying themes by identifying the natural questions that arise in your mind
https://medicinedepartment.blogspot.com/2023/08/project-illustration-of-how-to-process.html?m=0
[19/08/23, 10:43:34 AM] ~ Tejaswini Kandhada: OP number: 20210109274
A 38 year old female came to opd with complaints of suprapubic pain since 1 month ,B/L loin pain since 3 days which is radiating to b/l lower limbs,pricking type of pain and continuous in nature.
Urgency of urine +
No complaints of burning micturition
No decrease in urine output,no difficulty in passing urine
No C/O Fever , SOB , Constipation
N/K/C/O DM , HTN ,Asthma , Epilepsy , Thyroid , TB , CVA, CAD
On Examination:
Patient is conscious,coherent,cooperative
No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy
Temperature: Afebrile
PR:80bpm
BP:100/80mmhg
RR:16cpm
CVS:S1 S2+,no murmurs
CNS:NAD
RS:BAE+
No wheeze ,No crepts
P/A:soft,non tender
Daily routine:
Occupation:
Patient wakes up at 5am and freshens up and has breakfast around 7:30 am. Then she will do her daily household chores and goes to work at 10am she works as a shopkeeper and has her lunch by 1:30pm,completes her work by 9pm and then she comes back home and rests for an hour .Then she has dinner at around 10pm ,and goes to sleep around 11pm.
Her daily routine is not affected.
Advise: Plenty of oral fluids and rest
[19/08/23, 11:03:50 AM] ~ Tejaswini Kandhada: OP number: 20210617892
A 31 year old female came to opd with complaints of fever since 2 days associated with chills and rigors.
C/o generalized weakness since 2 days.
No C/O SOB , vomitings , loose stools
N/K/C/O DM , HTN ,Asthma , Epilepsy , Thyroid , TB , CVA, CAD
On Examination:
Patient is conscious,coherent,cooperative
No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy
Temperature: Afebrile
PR:82bpm
BP:110/80mmhg
RR:16cpm
CVS:S1 S2+,no murmurs
CNS:NAD
RS:BAE+
P/A:soft,non tender
Occupation:
She is a homemaker.
Daily routine:
Patient wakes up at 5am does her household chores and has breakfast around 7am. Then she will continue her daily household chores and has her lunch by 1pm,rest for an hour .Then she has dinner at around 7pm ,and goes to sleep around 9pm.
Her daily routine is not affected.
Advise: Adequate hydration and rest
[19/08/23, 11:27:11 AM] ~ Tejaswini Kandhada: OP number: 20230818741
A 57 year old male came to opd with complaints of SOB since 2 months.
No C/O Fever , chest pain, sweating , palpitations , cough , cold ,vomitings , orthopnea, PND ,
N/K/C/O HTN ,DM , Epilepsy , TB , CVA, CAD , Thyroid disorder
On Examination:
Patient is conscious,coherent,cooperative
No signs of pallor,icterus,cyanosis,clubbing,
lymphadenopathy
Temperature: Afebrile
PR:88bpm
BP:130/70mmhg
RR:26cpm
CVS:S1 S2+,no murmurs
CNS:NAD
RS:BAE+ , no added sounds
P/A:soft,non tender
Occupation:
He is a farmer.
Daily routine:
Patient wakes up at 5am and has breakfast around 7:30 am. Then he will go for work and has his lunch by 12 pm , rest for an hour and continues his work and then he comes back home at around 6 pm. He has dinner at around 7pm ,and goes to sleep around 9pm.
His daily activities have been affected due to his SOB . He was unable to work like before and the working hours has been decreased.
[19/08/23, 11:47:37 AM] ~ Tejaswini Kandhada: OP number: 20210118247
A 60 year old female came to opd with complaints of SOB at rest since 2 months not associated with chest pain, palpitations.
No c/o orthopnea,PND,pedal edema
No C/O Fever , burning micturition , pain abdomen , loose stools
N/K/C/O HTN ,DM , Epilepsy , TB , CVA, CAD , Thyroid disorder
On Examination:
Patient is conscious,coherent,cooperative
No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy
Temperature: Afebrile
PR:86bpm
BP:110/60mmhg
RR:18cpm
CVS:S1 S2+,no murmurs
CNS:NAD
RS:BAE+
P/A:soft,non tender
Occupation:
Daily wage labourer
Daily routine:
Patient used to wake up at 5am and has breakfast around 7 am and used to go for work by 9 pm and has her lunch by 12 pm , she used to come back home at around 6 pm ,has dinner at around 7pm ,and goes to sleep around 9pm but now due to SOB her daily activity has been affected and the patient is not gng for work since 2 months. Now she wakes up at 6am , has breakfast at 7:30 am,rest for an hour and watch TV for sometime then she has her lunch at 12 pm ,sleep for 2 hrs then watch TV and has dinner at 7pm and goes to sleep around 9pm.
Advice: Adequate rest
[19/08/23, 1:03:25 PM] ~ Tejaswini Kandhada: OP number: 20210112655
A 57 year old female came to opd with complaints of chest pain radiating to left upper limb , intermittent in nature and not associated with SOB and palpitations.
No C/O orthopnea,PND , vomitings , loose stools
K/C/O HTN since 20 yrs and on medication
DM since 2 yrs and on medication
N/k/c/o Epilepsy ,asthma,CVA , CAD
On Examination:
Patient is conscious,coherent,cooperative
No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy
Temperature: Afebrile
PR:81bpm
BP:120/80mmhg
RR:18cpm
CVS:S1 S2+,no murmurs
CNS:NAD
RS:BAE+
P/A:soft,non tender
Occupation:
She is a homemaker.
Daily routine:
Patient wakes up at 5am does her household chores and has breakfast around 7am. Then she will continue her daily household chores and has her lunch by 1pm,rest for an hour .Then she has dinner at around 7pm ,and goes to sleep around 9pm.
Her daily routine is not affected.
Advise: Adequate hydration and rest
[19/08/23, 1:05:48 PM] ~ Tejaswini Kandhada: OP number: 20230830230
A 30year old female came to opd with complaints of fever since 1week , chest pain since 1 month ( burning type of pain ) and pain in b/l loin region since 1 month.
High grade fever,continuous and relieved on taking medication.
SOB on exertion since 1 month
No c/o palpitations,orthopnea ,PND,cough,cold,vomitings
N/k/c/o HTN , DM , Epilepsy ,asthma,CVA , CAD ,TB
On Examination:
Patient is conscious,coherent,cooperative
No signs of pallor,icterus,cyanosis,clubbing,
lymphadenopathy
Temperature: Afebrile
PR:120bpm
BP:100/60mmhg
RR:16cpm
CVS:S1 S2+,no murmurs
CNS:NAD
RS:BAE+
P/A:soft,non tender
Occupation:
She is a homemaker.
Daily routine:
Patient wakes up at 6am , has breakfast around 7am. Then she will do her daily household chores and has her lunch by 1pm,rest for an hour .Then she has dinner at around 7pm ,and goes to sleep around 9pm.
Her daily activities are not affected.
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