drsaranya

Thursday 3 August 2023

A 70 Year old man with foot ulcer

I am Saranya ,currently an intern posted in the department of General Medicine

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Rotatory Internship Postings to enforce a greater patient centered learning

DEIDENTIFICATION :

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CONSENT :

An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.

ACKNOWLEDGMENT

I convey my regards to Dr. Lohith and Dr.Narsimha Reddy ( Resident , Department of General Medicine ) for guiding me regarding the case .

INTRODUCTION :

My patient is a 70 year old man, a labourer in young days,now retired, resident of a rural district of South India

CHIEF COMPLAINTS :

Our patient came with complaints of wound on Right foot since 2 years , fever since 1 day.

HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 years back when he gives history of trauma to right foot resulting in trauma ( thorn pricking on the sole of the right foot ) , that wound was not healing, since then there is ulcer on his right sole.
Patient has pain in his right foot, A/w pins and needles; tingling and numbness in both upper and lower limb.
Patient is having fever since 1 day.
High grade fever, intermittent , resolving with antipyretic medication

OTHER CO MORBIDITIES :

He is a k/c/o DM 2 , HTN since 2 years on oral medications.
No c/o SOB, Chest pain ,Palpitation orthopnea , PND , pedal edema
C/o frequency , urgency , dribbling of urine

Biopsychosocial history :

Patient is too old to go to work, previously he used to be a labourer but has stopped going to work, his wife has passed away, children have left the house ,settled in other parts of the city and they do not maintain contact with their father, he lives all alone in his rural house, no care taker, money and daily basic household needs are also a constraint for him. He came to the hospital by himself because he was troubled by his wound and fever had also added up.

His Daily Routine :
His day begins early in the morning when he needs to wake up even when he does not feel like, because he knows that he has to get going ,to fill vessels of water for the day, for drinking and household chores ,and after a certain time , the source water stops, hence that is the way the day begins ,
Even though the foot is painful, and he is weak with the burden of age and life events ,he has no other option but to pull himself up and head towards making some food for himself , he has somehow managed to buy a small cooking gas cylinder in which he cooks his 2 square meals of the day, which mostly comprises of rice and a curry
We wouldn't mind to eat a better variety and maybe a more healthier plate but his resources and energy to make the meals by himself is too constrained to even think of those options
This he does just for survival ,and because when in hunger he needs to eat atleast something , he also mentions a sentence saying( in his own language ; that I shall translate in English for the readers understanding
" My hunger has died , no don't think I don't feel hungry, I do ,but when I think ,again It is me who has to arrange everything , a part of the hunger vanishes ,and rest of it vanishes when I think that everyone in my life left me alone and left ".

After his meal preparation, he eats his food , takes some rest , and then again gets started in washing the used utensils , and once in couple of days cleaning the room.
Through the day, In between the works he tries to rest at times ,
In the late afternoons , some days he goes out to buy small necessary things ,going and coming back,takes a lot of time,since he walks slowly with the assistance of a stick.
He finishes his dinner,
And goes to bed.

Clinical Examination :(pictographical ) :

Blackish discoloration

Vitals :

BP: 140/ 80 hg
Pulse : 80 bpm
Rr : 14 cpm
Temperature: Febrile

History of self amputation of 3rd toe ( metatarsal and phalanx) ,toe had become shriveled and shrunken after which he went to a physician at a local region, who suggested the toe had to be taken off since it had " died "
Correlating with imageology

Xray right foot AP and Oblique

INVESTIGATIONS:

Friday 21 July 2023

Patient Centred Objective Structured Clinical Examination

I am Saranya ,currently an intern posted in the department of General Medicine

Greetings to all my readers

What can you expect out of this blog :

This blog is an objectively structured clinical examination example based on a real time patient whom I got acquainted to , during my General Medicine rotational internship posting .

The essence of this is to assess the clinical competence by reviewing the case reports shared below and to discuss, understand the patient problems, the related pathophysiology ,the core pharmacology needed to correct the dictation, and data analysis of patients so as to develop my clinical competency in comprehending clinical cases .

Instead of dealing with questions based on virtual case vignettes, this is a more close-to-real experience approach.

I shall at first share the link to the blog about the patient based on whom the OSCE questions shall be about

A quick glance through that blog would set the stage right to attempt the below stated questions :

Link : https://drsaranyaroshni.blogspot.com/2023/07/55-year-old-lady-with-difficulty-in.html

" As the Disease proceeds , the hand fails to answer with exactness to the dictates of the will "

-James Parkinson

Image Credits : Reynolds-Finley Historical library ,University of Alabama ,Birmingham ( which preserves and showcases the original copy of the Essay written by James Parkinson in 1817 )

It has been more than 200 years since the first case of this disease had been documented , via a comparative study try to document the signs and symptoms which were talked about at that time ,and the ones which are considered in today's day, with highlight upon any new additions or any deletions and studies supporting the same.

What all would you assess from a patient through his gait, appearance, body language and non verbal communication?

In other words , from the time the patient comes in through the doors of the physician's office till he/she sits himself on the chair and begins narrating his complaints ... what all clues can he/she already have given to your " Clinician's eye " ?

A video related to this case has been attached herein :

https://youtu.be/Equma9NCeCw

According to epidemiological data , what is the usual age of onset of Idiopathic Parkinson's Disease in an individual ?

Onset at what age and less would be considered as Young Onset Parkinsonism ?

What could be the etiology in such cases ?

Reference to our patient : Our patient is a 55 year old , presented to us with complaints of difficulty in walking since the past 6 months.

What all in the hand if the patient would guide more towards the diagnosis of Parkinson's Disease ?

What activities would you ask the patient to show in order to gather more points proving your Diagnosis?

Drawing a tangent from this case , in general which all Systemic pathologies can be suspected by hand and nail findings ?

What is the chemistry and balance of the neurotransmitters which get deranged in a patient of Parkinsonism ?

According to the above said pathophysiology , list out the rationale of the drugs which would be needed to correct the derangement

Though at first it may sound whack ,but a lot of research and documentation has already been done and is still on progess regarding certain Trained Dogs , and rarely some humans ,for instance Mrs.Joy Milne , a 72 year old Scottish lady who can " smell" the Parkinson's Disease .

Attached herein , are a few studies and research articles regarding the same , review the literature ,analyze the data and state your opinion .

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6487465/

https://www.bmj.com/content/378/bmj.o2247

https://www.apdaparkinson.org/article/the-smell-of-parkinsons-disease/

As a good clinician, we should always have more of a holistic thinking whereby we can list out differentials which can lead to the presentation that our patient has and then narrow down to the final diagnosis.

This would prevent missing out on any of the possiblities.

Very much like what Sherlock Holmes says

" Keep everyone in the suspect list , eliminate factors and what remains is the truth "

Out of the investigations listed herein , what all parameters if deranged would manifested with -

* Tremors

* Limb weakness

* Spasticity

* Lethargy

* Incoherence

Write about them and their respective mechanisms to lead to the symptom.

Treatment given to our patient.

Give a brief note about " on and off phenomenon " which is seen in patients after undergoing this therapy.

According to recent evidence based studies, which are the other newly developed pharmacological molecules which help patients suffering from the "on and off phenomenon "

Give a note about Tertiary level of prevention in Parkinson's Disease ( I.e Rehabilitation and Quality of Life Improvement in the patients ).

Several publications portray the role of regular aerobic exercises in maintaining satisfactory neouroplasticity of the Basal Ganglia , " Mediterranean Diet " ,diets low on dairy ,alcohol , high in caffeine, helping in slower progression of the degenerative process;

REFERENCE:

https://n.neurology.org/content/99/7_Supplement_1/42

Do you think adopting these measures in the mainstream treatment protocols along with more empathizing care giver models would ensure better outcome or are these things which look good only on pen and paper with negligible practical worth ?

Thursday 20 July 2023

55 year old lady with difficulty in walking

I am Saranya ,currently an intern posted in the department of General Medicine

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Rotatory Internship Postings to enforce a greater patient centered learning

DEIDENTIFICATION :

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CONSENT :

An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.

ACKNOWLEDGMENT

I convey my regards to Dr. Lohith and Dr.Narsimha Readdy ( Resident , Department of General Medicine ) for guiding me regarding the case .

INTRODUCTION :

My patient is a 55 year old lady, a homemaker , resident of a rural district of South India

CHIEF COMPLAINTS :

A 55 year old lady came with the complaints of difficulty in walking since the past 6 months.

c/o Left lower limb pain and Left lower limb weakness since 4 to 5 months both upper and lower limbs

Timeline of her disease process

( BioPsychosocial data compiled )

TRYING TO DOCUMENT THE LIFE OF OUR PATIENT IN THE FORM OF A STORY

( P.S. : HENCE TRIED TO CHOOSE A FONT WITH A SIMILAR FEEL )

Her day would begin with notes of prayers by her grandparents, there would be lush greenery all around as soon as she stepped out of home , thanks to the Indian village being her home.

Soon she would get her self ready and head out, ready to walk quite some distance to reach her wee little school where she enjoyed with her friends ,played and learnt too.

Coming back home , even though young she would lend a helping hand to her mother in the many household chores ,since they were a family of many , and she was expecting younger siblings too.

Our patient was born in a common Indian household in the 1960s .She was the second eldest among the four siblings.

She was raised in a rural background ,in a family where the parents were engaged in daily wage work ,earning square meals for their children ,but at the end of the day ,they were a happy family.

She still remembers how beautifully all her cousins ,her neighbors would come together and celebrate the festivities ,even though they would not be pompous ones but they would merry moments .

As they say , good times often pass in a blink , so went her childhood days ,as adolescence arrived ,soon the parents began the preparations of getting the daughters married , and it was her turn

But all stories do not have a happy ending ,there were some issues which cropped up between the two families , a kind of tension was built , and the very next day of her marriage her husband and her in-laws refused to accept her , hence she never went to her in -laws home.

This somehow affected her a lot as a person, she curled herself into a shell, reduced meeting up with people , avoided attending family functions,

With time ,all her siblings got married ,shifted off to different areas , and her parents passed away.

She began living all by herself, managing all the household chores , the economic side by engaging in daily labor work , and also carrying her emotional burdens . All by herself.

This was a quick snapstory about her background .

Timeline continued :

2 years back : History of slip and fall , trauma to left wrist , which was managed conservatively ( according to the patient ,documented records not available )

Post treatment she became fine ,and remained alright until 6 months back when she had developed difficulty in walking, due to which is unable to do her routine work .

She also could not lift heavy weights, hence had to stop going to her labor work.

she also had complaints of

weakness in left lower and upper limbs,

weakness is insidious onset gradually progressive in nature

Pain and tenderness present in the deltoid area (left side) and pain aggravated on over head abduction and tenderness present.

Patient complaints of " shooting type " of pain in the left lower limb from hip to toe, which is aggravating on walking,

Due to pain Pateint while walking she feels as if she’s going to fall down

c/o pain in the left deltoid region since 5 to 6 months with c/o pain during movement .

No h/o head trauma and LOC

No ent bleed

Not aK/c/o HTN, DM CVA CAD,TB asthma etc

Quick glance at her gait.

Click on this link

https://youtu.be/Equma9NCeCw

https://youtu.be/Equma9NCeCw

General and Systemic Examination:

CLINICAL PICTURES :

CVS Examination : S1 , S2 heard , no murmurs

Respiratory Sys. Ex : Normal bilateral air entry ,normal vescicular breath sounds heard , no added sounds.

P/A : Soft and non tender.

CNS Examination

Reflexes Rt. Lt

Biceps. +++ +++

Triceps. + +

Supinator +++ +++

Knee + +

Ankle ++ ++

Plantar Flexion Flexion

Tone Right Left

Upper Limb Hypertonia Hypertonia

Lower Limb Hypertonia Hypertonia

Power Right Left

Upper Limb 5/5 5/5

Lower Limb. 5/5 4-/5

Bradykinesia present ,

Patient stumbles at turnings

B/L Asymmetric Cogwheel rigidity

Festinating gait

Decreased arm swing and mask like facies

INVESTIGATIONS :

Orthopedics and Neurophysician opinion taken.

Advice by Orthopaedician : No immediate intervention needed from their end.

Advice by Neurophysician : Clinically, Patient diagnosed with Idiopathic Parkinson's Disease

PROVISIONAL DIAGNOSIS

IDIOPATHIC PARKINSONS DISEASE

TREATMENT GIVEN

INJ.OPTINEURON IN 100 ML N.S IV /OD

TAB.PREGABALIN-M 75MG PO/HS

TAB. SYNDOPA PLUS 125MG 1/2 PO/BD

Advice at Discharge

TAB.SYNDOPA PLUS 125MG 1/2 PO/BD 8AM-8PM X 14 DAYS

TAB.MVT PO/OD X14 DAYS

75 year old male patient with quadriparesis

I am Saranya ,currently an intern posted in the department of General Medicine

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Rotatory Internship Postings to enforce a greater patient centered learning

DEIDENTIFICATION :

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CONSENT : An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.

ACKNOWLEDGMENT

I convey my regards to Dr. Lohith and Dr.Narsimha Readdy ( Resident , Department of General Medicine ) for guiding me regarding the case .

Documentation :

is being done on 20th July 2023

(Updates will be done later in the future with dates mentioned for the same.)

INTRODUCTION :

My patient is a 75 year old man , resident of a rural district of South India

CHIEF COMPLAINTS :

A 75 yearold male came to casualty with chief complaintsof weakness of left upperlimb and lowerlimb since 2 days

Clinical pictures

Lateral and Front profile

Conjunctiva

? Frank Sign

HOPI:

Patient was apparently normal 2 days back he then developed weakness of left upperlimb and lowerlimb which was insidious in onset and gradual in progression.

No C/O deviation of mouth

Neck pain+

No C/O headache, vomiting, blurring of vision

C/O constipation-passes stool in every 2days

Decreased urine output since 2 days

No pedal edema, facial puffiness

Mild SOB grade2

Biopsychosocial Corelation:

Patient used to live in their village house with his wife ,son ,daughter in law and grandson

Until 6 months from today, he used to go to his fields everyday for ploghing and seed sowing work but his wife began falling sick, she developed paresis ,inability to move and became completely confined to the bed .

To support her and also carry out certain chores ,he stopped going to the fields and stayed at home the entire time ,taking care of the wife.

His wife passed away 5 days back which left a big mark on him and he kept complaining that he wasn't feeling fine since then , after which his situation worsened and 1 day back he was brought to our medical institution

USUAL DAILY ROUTINE AND DERANGEMENT DUE TO DISEASE

He would get up 6 am in the morning, freshen up, have breakfast at 7 am and go off to the agricultural fields for work, he would come back home for lunch at 1 pm ,take some rest and go back to his fields for another hour or two at around 3 pm.

Evenings usually he used to spend time with his family and neighbours ,have his dinner at around 7 pm and go to bed.

Although the patient has been experiencing these symptoms from around 1 week back but it has severely deranged his daily life, unlike before he is unable to any of this daily work independently and needs help all round the clock.

PAST HISTORY:

Patient was diagnosed as hypertensive 3 days back but not put on any medication

N/K/C/O DM, TB, epilepsy, CVA, CAD, thyroid disorders and bronchial asthma

EXAMINATION:

Patient is conscious and oriented

PR:96bpm

BP:120/80mmHg

RR:14cpm

RS:BAE +no added sounds

CVS:S1, S2 heard. No added sounds

P/A:soft, nontender

Cns examination :

Patient is conscious , coherent and oriented to time ,place and person.

Higher mental functions are intact.

Patient has neurogenic bladder which was releived after insertion of foleys catheter.

Tone -normal in all four limbs

Power rt lt

4-/5 4-/5

Reflexes

B T S K A P

++ ++ + + + Flexion

Neurogenic bladder

Note : on 19/7/23 evening , Patient accidentally hit the wall and suffered a laceration in the frontal region of the head.

Suturing and wound care was done for the same.

Wound before suturing

Sutures secured

Electrophysiological study

Radioimaging

Friday 7 July 2023

OPD Data Audit Archive From 13th June 2023 to 11 th August 2023

Greetings to the readers

I am Saranya , I am currently pursuing my MBBS internship .

This is the collation of the OPD audit which is done on a daily basis ,and the related discussions .

Hereby you can find the data collected from the patients seen from : 13th June 2023 to 11th August 2023

13th June 2023

[13/06, 16:13] Dr. Rakesh biswas: What is the role of sporolac in acute community acquired diarrhoea?

What is the localization of large volume diarrhoea?

What is the role of razo d in acid peptic disease?

@⁨Saranya⁩ Please check the previous archived links in the description box

[13/06, 16:14] Dr. Rakesh biswas: How many seen and how many admitted @⁨Lohith Sir Gen Med⁩ @⁨Dr. bharath Gen Med⁩

[13/06, 16:52] Saranya: Ok sir

I ll check the previous links

[13/06, 17:46] Srivani: Sir lasix can be given to this patient to treat fluid retention and swelling

[13/06, 17:47] Srivani: Sir , Sporolac helps increase the absorption of nutrients by increasing the number of good bacteria in the intestine. Lactic acid bacillus works by inhibiting the growth of harmful microorganisms in the gut and makes the environment unfavourable for the growth of harmful bacteria.

[13/06, 17:48] +91 90001 66698: Please share the efficacy trial

[13/06, 17:49] Srivani: Ok sir

[13/06, 17:51] +91 90001 66698: How did we arrive at community acquired diarrhea diagnosis?

Any h/o of contacts?Outside food?

[13/06, 17:53] +91 90001 66698: How's the stool?

[13/06, 17:53] +91 90001 66698: Febrile?

[13/06, 17:54] Srivani: Sir, Patients with large volume diarrhea have disease of upper intestinal tract secondary to either an osmotic or secretory process.

[13/06, 17:54] +91 90001 66698: Large volume?

How much is the volume?

What's the frequency?

[13/06, 17:55] Srivani: Razo-D is used to treat gastroesophageal reflux disease (Acid reflux) and peptic ulcer disease by relieving the symptoms of acidity such as heartburn, stomach pain, or irritation. It also neutralizes the acid and promotes easy passage of gas to reduce stomach discomfort

[13/06, 17:57] +91 90001 66698: What's the rationale behind prescribing rabeprazole over pantaprazole?

Any h/o heart condition?

CYP pathway?🤔

[13/06, 18:18] Srivani: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1123310/

[13/06, 18:19] +91 90001 66698: Antibiotic diarrhea?

Is the patient on any antibiotics previously?

And also do those antibiotics in anyway effect the probiotics such as lactobacillus you prescribed?🤔

[13/06, 19:01] Dr. Rakesh biswas: I'm asking what we did not what can be done!

[13/06, 19:02] Dr. Rakesh biswas: Any scientific reference?

[13/06, 19:03] Dr. Rakesh biswas: What symptoms of acidity did your patient have?

[13/06, 19:03] Dr. Rakesh biswas: Did your patient have antibiotic associated diarrhoea?

14th June 2023

[14/06, 09:33] +91 83741 92025: Op no:1

A 50 year old female came with c/o

-Burning micturition since 1 month (on and off)

No hesitancy, urgency,or increased frequency

-C/o fever since 1 month which is low grade on and off relieved on medication

-c/o cold since 2 months,

Cough since 10 days (dry cough )

Significant weight loss (12 kgs)

H/o occasional palpitations

N/k/c/o HTN DM THYROID DISORDERS ASTHMA

O/E:

Pt is c/c/c

Afebrile

PR:70 bpm

BP: 120/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,nontender

Patient advised for admission but not willing to admit

[14/06, 09:42] Vaish :): OP: 20210109474

A 45 year old female came with c/o vomitings since yesterday, 3 episodes with food as content, non bilious, non projectile.

C/O loose stools since yesterday, 4 episodes, non blood stained

H/O low grade fever since yesterday, intermittent in nature, not associated with chills and rigors

No H/O outside food consumption or spicy food intake

K/C/O asthma since 10 years, using inhaler during attacks.

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

O/E :

Pt is c/c/c

PR: 72 bpm

BP: 120/80 mmHg

RR: 17 cpm

CVS : S1,S2 +

CNS: NAD

RS: BAE+,NVBS+

P/A : soft, nontender

[14/06, 09:43] Vaish :): Patient advised for admission but not willing to admit.

[14/06, 10:14] +91 83741 92025: Op : 20230404467

A 45 year old male came with c/o B/L pedal odema since 1 week pitting type extending upto knee

c/o decreased urine output burning micturition

No c/o tingling and numbness of both upper limb and lower limb

No polyphagia,polyuria,nocturia

K/c/o DM type 2 since 1 year and on medication (tab Glimperide 1 mg, tab metformin 500 mg)

O/E:

Pt is c/c/c

Afebrile

PR:78bpm

BP: 140/100 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Patient advised for admission but not willing to admit

[14/06, 10:16] Vaish :): OP: 20230619833

A 55 year old female came with c/o tingling and numbness in bilateral lower limbs since 1 year

H/O slippage of foot wear

C/O polyphagia, polydypsia, nocturia

C/O blurring of vision since 1 year

No c/o fever, vomiting, diarrhoea

No H/O sob, chest pain, palpitations

K/c/o DM type 2 since 15 years, on medication Inj HAI 25 U (morning) and 20U (night).

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

O/E :

Pt is c/c/c

PR: 92 bpm

BP: 120/80 mmHg

RR: 17 cpm

CVS : S1,S2 +

RS: BAE+,NVBS+

P/A : soft, nontender

Sensory examination:

Spinothalamic tract:

Light touch - Absent in L5-S1 dermatomes both lower limbs

Pain - Decreased sensation in L5-S1 dermatomes in both lower limbs

Dorsal column:

Proprioception: 6/10 (RightLL), 5/10(Left LL)

Cortical sensation:

2 point discrimination - Absent in L5-S1 dermatomes in B/L lower limbs

Graphesthesia - Normal B/L lower limbs

Stereognosis - Normal B/L lower limbs

Diagnosis: Diabetic Neuropathy

[14/06, 10:20] +91 83741 92025: Op :20230619852

A 55 year old female came with c/o B/L pedal odema since 15 days pitting type extending upto the knee

Decreased urine output since 5 days

No c/o burning micturition

No c/o fever cough and cold

k/c/o HTN since 1 month and on medication (tab Telma 40 mg )

Detected DM 2 1 month back but not on medication

O/E:

Pt is c/c/c

Afebrile

PR:86bpm

BP: 120/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Patient advised for admission but not willing to admit

[14/06, 10:23] Chinti: OP: 20230619832

C/O : difficulty in swallowing (solids more than liquid)

Associated with belching since 4 months

Burning sensation of foot present since 1 year

K/c/o DM since 2 years

K/c/o bells palsy since 4 months (resolving)( Lt LMN type)

Not a/w regurgitation of food

Abdominal distension after food intake

A/w belching

Burning sensation (retrosternal) present increases with spicy food intake

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

O/e:

Pt c/c/c

Oriented to time, place and person

BP: 120/80mmHg

PR: 78bpm

CVS: S1S2 present

RS: NVBS+

P/A soft, non tender, bowel sounds+

CNS:

R. L

B. 2+. 2+

T. 2+. 2+

S. 2+. 2+

K. 2+. 2+

A. 2+. 2+

Pain

UL. N. Decreased

LL. N. N

Touch

UL. N. N

LL. N. N

Pressure:

UL. N. N

LL. N. N

Proprioception:

UL: 7/10

LL: 7/10

7th CN examination:

Frowning +

Deviation of mouth slightly to left

Buccinator normal

Closing eyelid+

Nasolabial fold decreased to Rt side, prominent to left side

T. Pan 40 po of X5d

Syp. Sucralfate po od 15 ml for 1 week

T. GABA NT PO HS

T NEUROBION FORTE PO OD

Strict diabetic diet/ walk 20 mins

[14/06, 10:27] Chinti: Patient advised for admission, but patient not willing for admission

[14/06, 10:40] Chinti: OP: 20210216928

A 42F a k/c/o DM since 2 months on medication came to the OPD for follow up

No H/O polyuria, polydipsia, polyphagia

No H/O burning micturation

No h/o tingling or numbness

No facial puffiness

Inv done on 13/6/23

FBS: 121 mg/dl

PLBS: 151 mg/dl

O/E:

Pt is c/c/c

Afebrile

PR:72bpm

BP: 110/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Strict diabetic diet

T METFORMIN 500MG PO OD before food

T PAN 40 PO BBF

[14/06, 10:55] Chinti: OP: 20230620281

34M came to OPD with c/o

B/l pedal edema since 20 days, pitting type, releived on rest and aggrevated on walking, associated with tingling and numbness occasionally

Retrosternal burning sensation present

Regurgitation of food particles present

No decreased urine output, facial puffiness, abdominal distension

C/o lower back ache since 15 days, increased after RTA 3 days back

A/h/o rta 3 days back

Head injury +

No h/o LOC, ENT bleeds, seizure like activity, vomitting

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

Non smoker, non alcoholic

O/E:

Pt is c/c/c

B/L pedal edema+ grade 2

Afebrile

PR:85bpm

BP: 134/110 mmHg

CVS:S1S2+,no murmurs, JVP not raised

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,non tender, bowel sounds+

Patient advised for admission but not willing to admit

[14/06, 11:07] Chinti: OP 20230620275

A 35 M came to the OPD with c/o pain abdomen, burning type, in the retrosternal region since 6 months

Aggrevated on spicy food intake and releived on bland food intake, associated with regurgitation of food

Belching present

Constipation present

Yellowish discoloration of urine present

No nausea and vomiting

Consumes alcohol: 180ml 3-4 times a week

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

O/E:

Pt is c/c/c

Afebrile

PR:75bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs, no raised JVP

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Diagnosis: Acid peptic disease

Patient advised for admission but not willing to admit

[14/06, 11:09] +91 83741 92025: Op:20210503214

A 46 year old female came with c/o pain abdomen ( in the left hypochondriac region) since 1 month

No H/o lowback ache since 1 month radiating down to B/L lower limbs

No nausea, vomiting, fever

O/E:

Pt is c/c/c

Afebrile

PR: 78 bpm

BP: 140/100 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,tenderness present in left hypochondrium

Spleen is palpable 6cm from the left costal margin

Patient advised for admission but not willing to admit

[14/06, 11:11] Vaish :): OP: 20210315477

63 year old male came to OPD with c/o distension of abdomen since 1 week.

C/O sob since 1 week , Grade II-III , no chest pain, no palpitations

H/O decreased urine output, hesitancy + since 1 week

H/O Angiogram done 6 months back

H/O spine operation 1 year back

K/c/o chronic alcoholic since 40 years

K/c/o Type 2 DM since 5 years and on medication (not available)

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

Non smoker

O/E:

Pt is c/c/c

Afebrile

PR: 78 bpm

RR: 17 cpm

BP: 100/60 mmHg

CVS: S1S2+,no murmurs

CNS: NAD

RS: BAE+NVBS+

P/A: Soft ,non tender

Patient advised for admission but not willing to admit

[14/06, 11:29] Chinti: OP: 20230620244

A 50M came to GM OPD with c/o :

Burning micturation since 4 days

Fever since 3 days

Vomiting since yesterday

Fever associated with chills and rigors, evening rise of temperature present, associated with burning micturation, releived on medication

Occasional productive cough

No constipation, sore throat

Vomiting present 5 mins after consuming water/food, non projectile, no bilious, food and water as contents, non blood tinged

No decreased urine output, no facial puffiness

K/c/o: abdominal wall herniation (resolved)

Smoker: 18 beedis/day, stopped 3 days ago

O/E:

Pt is c/c/c

febrile to touch

BP: 100/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+ , fine basl crepts present

P/A: soft ,non tender

[14/06, 11:47] +91 83741 92025: Op: 20210217754

A 45 year old female came with c/o decreased appetite since 4 days

C/o fever associated with chills and rigors since 4 days

H/o loose stools 4 episodes ( watery,non blood stained )

C/o SOB grade 3 insidious in onset gradually progressive since 4 days

Orthopnea absent

No chest pain and palpitations

N/k/c/o DM HTN thyroid disorders and asthma

O/E:

Pt is c/c/c

Afebrile

PR:80 bpm

BP: 90/50 mmHg

RR: 24 cpm

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Patient advised for admission and willing to admit

[14/06, 11:49] Chinti: OP: 20230620846

A 34 F came to the GM OPD with C/O unilateral throbbing type of headache. Duration: overnight (approx: 12hrs)

Releived on medication and sleep. Associated with generalized body pains and easy fatiguability.

Phonophobia, photophobia present. Associated with nausea.

No vomiting, not associated with aura.

Usually 5 times a month.

Triggers: sunshine, cold weather, sleep deprivation.

On unknown medication.

K/N/C/O: HTN, DM, TB, CAD, Asthma, Epilepsy.

O/E:

Pt is c/c/c

Afebrile

PR:86bpm

BP: 120/80 mmHg

CVS:S1S2+,no murmurs

CNS: HMF intact

NFND seen

No scalp tenderness

Cranial nerves normal

RS: BAE+NVBS+

P/A: soft ,non tender

Diagnosis: Migraine

[14/06, 12:39] Chinti: OP: 20230620360

A 42F came to the GM OPD with generalized body pains since 2 months.

Pt is a k/c/o : hypothyroidism since 2 months under medication, thuronorm 12.5 mcg. Stopped taking 20 days ago,

Patient developed palpitations and SOB after taking thuronorm tablets and hence stopped taking them. No weight loss or gain, heat or cold intolerance, pain abdomen, fever. N/K/C/O: HTN, DM, TB, CAD, Asthma, Epilepsy.

O/E:

Pt is c/c/c

No pallor, edema or exophthalmos

Afebrile

PR:75bpm

BP: 130/70 mmHg

CVS:S1S2+,no murmurs

No raised JVP

CNS: NAD

RS: BAE+NVBS+

P/A: soft ,non tender

SLRT: Rt: + 70°

Lt: + 60°

No paraspinal stiffness

Normal disc spaces

Patient advised for admission but not willing to get admitted

[14/06, 12:47] +91 83741 92025: Op:20230620897

c/o chest pain since 1 year

c/o palpitations since 2 months

No pedal odema or decreased urine output

C/o burning micturition since 3 months

C/o burning sensation of lower limbs since 2 months

No numbness

C/o lower backache since 2 months radiating down to lower limbs

K/c/o HTN since 4 years and on medication

Not a k/c/o DM thyroid disorders asthma

O/E:

Pt is c/c/c

Afebrile

PR:82 bpm

BP: 140/90 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft,non tender

Patient advised for admission but not willing to admit

[14/06, 14:50] +91 83741 92025: Op: 20230621174

-C/o decreased flow of urine since 10 days

-C/o burning micturition

- B/L pedal odema + pitting type

-c/o tingling and numbness in the both limbs

-c/o shoulder pain since 5 months

K/c/o DM2 ,HTN since 15 years ( tab metformin 500 mg )

H/o TB 2 years back

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

O/E:

Pt is c/c/c

Afebrile

PR:84 bpm

BP: 130/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Patient advised for admission but not willing to admit

[14/06, 16:23] Dr. Rakesh biswas: What was done for him?

[14/06, 16:27] Dr. Rakesh biswas: What was the clinical diagnosis for his abdominal distension?

[14/06, 16:28] Dr. Rakesh biswas: What was done for him? What was your diagnosis?

[14/06, 16:58] Chinti: Sir, the patient likely has a UTI.

[14/06, 18:05] Vaish :): Sir, most likely the patient has ascites

[14/06, 18:33] Dr. Rakesh biswas: What were your clinical findings of ascites? You simply mentioned soft and non tender abdomen?

[14/06, 18:38] Vaish :): Sir, shifting dullness sign positive

15th June 2023

[15/06, 10:01] Jahnvi 2k18: Op: 20210509489

A 58M patient came to GM opd with tingling and numbness in bilateral lower limbs since 2 months

Pt is a k/c/o DM since 4 years

He is taking Glimiperide2 mg and metformin 500 mg PO OD

Not a k/c/o HTN, TB, Epilepsy, CVA, CAD

O/E:

Pt is c/c/c

No pallor, edema, clubbing, cyanosis, lymphadenopathy

Afebrile

PR: 78bpm

RR: 18cpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

No raised JVP

CNS: NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Patient advised for admission but not willing to get admitted

[15/06, 10:11] Dr. Rakesh biswas: Please share what is your plan after admission

[15/06, 10:15] Rohit Dharma: op no 20230622118

43/F

C/o left sided headache since 3 months (frontal and temporal)

Associated with aura,photophobia,phonophobia

Headche more with the stress

C/o of neck pain radiating to the left hand

Tingling sensation and pain in left upper limb since 5 days

No h/o fever,cold, cough

No h/o vomiting

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 -

GCS - E4VM6

TONE: RT. LT

UL NORMAL. NORMAL

LL NORMAL NORMAL

POWER:

UL 5/5. 5/5

LL 5/5. 5/5

REFLEXES:

B: 2 + 2+

T: 2+ 2 +

S: 1+ 1+

K: 2 + 2+

A: 2+ 2+

P: Flexion. Extension

[15/06, 10:35] Jahnvi 2k18: After admission his complete Grbs monitoring and his response to current anti diabetic medication.

[15/06, 10:38] Rohit Dharma: Op no 20230622144

45/M

C/O Abdominal pain since 3 months

Pain relieves after eating food

No radiation of pain

No h/o fever,cough, sob

No h/o vomtings, loose stools

/K/c/o Hypertension, DM type 2 since 5 years N/K/c/o epilepsy,CVA,CAP,Bronchial asthma,thyroid disorders

O/e

Patient was c/c/c

Vitals-

Temperature - afebrile

Bp- 100/60

PR- 84bpm

RR-18cpm

CVS - s1 s2 heard, no murmurs

CNS - NAD

RS - BAE+,NVBS

[15/06, 11:05] Rohit Dharma: Op no 2021316667

46/F

C/O chest pain since 1 month

Squeezing type of pain

Non radaiting type of pain

Pain more after eating food

Occasional history of shortness of breathe for > 2kms

N/H/o palpatations, pedal edema,giddiness

N/H/o vomitings,loose stools,pain abdomen

N/K/c/o Hypertension, DM,asthma,epilepsy,CVA,CAP,Bronchial asthma,thyroid disorders

O/e

Patient was c/c/c

Vitals-

Temperature - afebrile

Bp- 100/60

PR- 92bpm

RR-18cpm

CVS - s1 s2 heard, no murmurs

CNS - NAD

RS - BAE+,NVBS

Patient was advised for admission but not willing for admission

If She is admitted I Will advise for ECG ,chest X ray, check for any changes and treat accordingly to the reports

[15/06, 11:51] Rohit Dharma: Op no 20230622727

54/F

C/o fever since 2 days

Insidious onset, intermittent , not associated with chills and rigors , releived on taking medication

Dry cough +

Cold +

Headache +

Bodypains +

No C/o Nausea , vomitings , loose stools

N/K/c/o Hypertension, DM,asthma,epilepsy,CVA,CAP,Bronchial asthma,thyroid disorders

O/e

Patient was c/c/c

Vitals-

Temperature - afebrile

Bp- 100/60

PR- 92bpm

RR-18cpm

CVS - s1 s2 heard, no murmurs

CNS - NAD

RS - BAE+,NVBS

Patient was advised for admission but not willing for admission

[15/06, 12:01] Jahnvi 2k18: Op: 20230622752

40/M

C/o pain in the right hypochondriac region since 4 days , insidious in onset , intermittent, no aggrevating and relieving

K/c/o alcoholic liver disease

( H/o previous hospital admission)

K/c/o DM since 6 years - on regular medication

N/K/C/O: HTN,TB, CAD, Asthma, Epilepsy, CVA , CAD

O/E :

Pt is c/c/c

No pallor, edema , lymphadenopathy, clubbing, cyanosis

Afebrile

PR:82bpm

BP: 130/90mmHg

CVS:S1S2+,no murmurs

No raised JVP

CNS: NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Patient advised for admission but not willing to get admitted

[15/06, 12:06] Rohit Dharma: Op no 2023062277

46/F

C/o burning sensation in epigastric region since 6 months

No h/o chest pain, vomitings , loose stools

No h/o loose stools pedal edema,sob

K/c/o DM since 6 months on unknown medication

N/k/c/o hypertension asthma,epilepsy,CVA,CAP,Bronchial asthma,thyroid disorders

O/e

Patient was c/c/c

Vitals-

Temperature - afebrile

Bp- 110/60

PR- 75bpm

RR-18cpm

CVS - s1 s2 heard, no murmurs

CNS - NAD

RS - BAE+,NVBS

[15/06, 12:24] Jahnvi 2k18: Op: 20230622782

38/F

C/o headache since 1 month

No blurring of vision

No H/o nausea , vomiting , photophobia , phonophobia

C/o neck pain since 2 months

No restriction of movements

No tenderness

K/c/o hypothyroidism since 12 years on T. Thyronorm 75mg

N/K/C/O: HTN, DM, TB, CAD, Asthma, Epilepsy.

O/E:

Pt is c/c/c

No pallor, edema or exophthalmos

Afebrile

PR:75bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

CNS: NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Patient advised for admission but not willing to get admitted

[15/06, 12:40] Rohit Dharma: Op no 2023062277

46/F

C/o chest pain left side > right since 3 days

Pain more after eating food

No radiation of pain

Shortness of breathe on excertion( grade 2)

No h/o pedal edema,loose stools, vomiting,pain abdomen

H/o occasional palpatation present

N/k/c/o hypertension asthma,epilepsy,CVA,CAP,Bronchial asthma,thyroid disorders

O/e

Patient was c/c/c

Vitals-

Temperature - afebrile

Bp- 120/80

PR- 88bpm

RR-18cpm

CVS - s1 s2 heard, no murmurs

CNS - NAD

RS - BAE+,NVBS

[15/06, 14:54] Sowji Kims: Op: 20230623232

A 39 year old male came with c/o swelling in right lower limb since 15 days

H/o fever 10days ago then later subsided

No H/o trauma

No H/o polyuria,polyphagia,polydipsia

H/o similar complaints 2years ago

K/c/o type 2DM since 3years on unknown medication

N/k/c/o HTN, thyroid disorders and asthma

O/E:

Pt is c/c/c

Afebrile

PR:80 bpm

BP: 110/60 mmHg

RR: 22 cpm

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

[15/06, 14:58] Vasanthi: Op.no:-20230616389

39 M

Patient complains of snoring and weight gain (8 kgs in two months)

Complains of insomnia since 2 months

History of head trauma two months ago

Not k/c/o HTN, DM, CVA CAD TB Asthma

History of weight gain due to decreased activity since 2 months following head injury

History of Anemia (moderate 7)

SOB on exertion

On and off pedal edema

No cough

Wakes up in middle of the night

On examination

Pt is c/c/c

No pallor icterus cyanosis clubbing lympadenopathy

CVS S1 s2 heard no murmurs

RS BAE +

P/A soft NT

CNS NFND

[15/06, 15:03] Vasanthi: Op.no:-20210219889

35 M

C/O abdominal pain since 8months apparently asymptomatic 8 months ago then developed epigastric pain, non radiating type, Aggravated on eating food and lying down

No relieving factors

Not associated with weight loss, loss of appetite,fever, vomiting

- H/O visit to hospital 8 months back

On examination:

Pt is c/c/c

No pallor icterus cyanosis,clubbing,lympadenopathy

B/L Pedal edema present (pitting type)

CVS S1 s2 heard

no murmurs

RS BAE +

P/A tenderness in epigastric region

CNS NFND

[15/06, 15:05] Sowji Kims: Op :20230623248

36 M

C/O chest pain associated with chest tightness since 15days

C/O difficulty in breathing after walking till 1km

Since 15days

No c/o palpitations,cough,fever

C/O neck pain since 1month radiating from cervical spine area to lumbar spine

N/k/c/o DM,HTN,TB,Thyroid disease,asthma,epilepsy

O/E

Pt is c/c/c

No pallor,icterus,cyanosis, clubbing ,lymphadenopathy,edema

BP-120/70mmhg

Pr-80bpm

Cvs-s1s2+,no murmurs

R/s-BAE+,NVBS heard

CNS-HMF intact

P/A-soft,non tender

[15/06, 15:08] Vasanthi: Op no:-20210315992

22 F

Patient c/o cold since 3 days

C/o fever and associated with chills and rigors intermittent

No cough

No burning micturition

No pain abdomen

No other complaints

Not k/c/o HTN, DM, CVA CAD TB Asthma

On examination

Pt is c/c/c

No pallor icterus cyanosis clubbing lympadenopathy

BP-110/80mmHg

PR- 84bpm

CVS S1 s2 heard, no murmurs

RS BAE +

P/A soft NT

CNS NFND

[15/06, 15:13] Sowji Kims: Op :20230624210

30 M

C/o fever since 1 week high grade, persistent associated with sweating and chills

History of vomitings 3 to 4 episodes which is non-bilious non-projectile

History of body pains since one week

History of pedal edema till ankle one week back and decreased three days ago

Not associated with cough and cold

No history of rash .

Past history :

Known case of asthma since 12 years ( intermittent nebulisation)

Not k/c/o HTN, DM, CVA CAD TB

On examination:

Pt is c/c/c

No pallor ,icterus, cyanosis ,clubbing, lympadenopathy

B/L Pedal edema present (pitting type)

Bp-110/70mmhg

PR-76bpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :tenderness in epigastric region

CNS :NFND

[15/06, 15:29] Vasanthi: Op.no:- 20230622784

40 F

Patient came to opd with c/o pain in epigastric region since 1 month

Which is insidious in onset, intermittent,non-radiating and burning type of pain.

No aggravating and relieving factors.

H/o palpatations and sweating since 2 weeks

No h/o vomitings, fever,loose stools,sob

N/k/c/o DM,HTN,ASTHMA,TB,CVA,CAP, Thyroid disorders

O/E:-

Pt is c/c/c

No pallor,icterus,cyanosis,clubbing and lymphadenopathy

Bp-120/70mmHg

Pr-80bpm

Cvs: S1 S2 heard,no murmurs

RS:BAE+

P/A: Tenderness in epigastric region

CNS:NFND

[15/06, 15:34] Sowji Kims: Op :20230623241

24 M

C/o pain in epigastric region since 1 month,non radiating pain.

No H/o palpitations.

No H/o sweating.

H/o shortness of breath+ grade (I-II) intermittently.

C/o left shoulder pain since 1 month non radiating.

no restriction of movements .

No H/o vomiting,loose stools

Past history :

Not k/c/o HTN, DM, CVA CAD ,TB ,Asthma

On examination:

Pt is c/c/c

No pallor ,icterus, cyanosis ,clubbing, lympadenopathy,edema

Bp-110/70mmhg

PR-75bpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :tenderness in epigastric region

CNS :NFND

[15/06, 15:48] Vasanthi: Op.no:20230622836

43 F

C/o fever since 3days low grade, persistent, not associated with chills and rigors

History of b/l upper limb and lower limb pain since 2 weeks

Not associated with cough and cold

No history of rash .

Past history :

Known case of hypothyroidism since 3months on medication of Tab.Thyronorm 50mcg

Not k/c/o HTN, DM, CVA CAD,TB

On examination:

Pt is c/c/c

No pallor ,icterus, cyanosis ,clubbing, lympadenopathy

BP:-100/70mmHg

Pr:-82bpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :soft and non tender

CNS :NFND

[15/06, 16:13] Dr. Rakesh biswas: Plan after admission?

[15/06, 16:15] Dr. Rakesh biswas: Tell us more about the burning sensation in her epigastrium. What is her hourly routine and when does she experience it for how long?

[15/06, 16:16] Dr. Rakesh biswas: Clinical Images of visceral fat and muscle mass for all your patients?

[15/06, 16:33] Rohit Dharma: We will do Appropriate tests and fever chart monitoring

[15/06, 16:33] Rohit Dharma: And symptomatic treatment

16th June 2023

[16/06, 10:28] Harika 2k18 Junior: Op no-20230623904

A 30 year old female patient came with complaints of neck pain since 1month .c/o swelling on the right side of neck since 20 days .

Patient complains of neck pain on flexion to right side,non radiating type .

No H/o trauma .

Not ak/c/o DM,Htn,Cad,CVA, thyroid disorders .

On examination:

Pt is c/c/c

Bp-90/60 mmHg

Pr- 80bpm

Temperature -afebrile

Rr-17cpm

Cvs- S1,S2 heard no murmurs

Rs-BAE+ NVBS Heard

P/A - Soft and nontender

Cns- HMF +.

[16/06, 10:32] Tejaswi 2k18 Surgery Unit 6: opd: 20230623562

A 55 yr old female patient came to the opd with C/o pain in the left hypochondrium , pain radiating to epigastrium since 1 month.

Associated with difficulty in breathing( walking for 200mts) since 1 month

C/o indigestion since 1 month

C/o food stuck in oesophagus

C/o burning sensation over the epigastric region since 1 month

Past History:

H/o hypertension since 2 years

Medication: telma 40

General examination:

No pallor, icterus, clubbing, cyanosia ,lymphadenopathy, pedal edema

Temp: Afebrile

Pr:88 bpm

Rr: 20 cpm

Bp:110/70 mm Hg

Systemic examination:

Cvs : S1 S2 heard,No murmurs

CNS: nfd

Rs: blae present

Per abd: soft, non tender

[16/06, 10:39] Tejaswi 2k18 Surgery Unit 6: Op no: 20230623569

C/o neck pain and headache when agitated since 4 years.

Past History:

K/c/o hypertension since 4 years

Usage of medicaine- Amlodipine 5 mg PO/ od since 1 month only.

General examination:

No pallor, icterus, cyanosis, clubbing,lymphadenopathy,

pedal edema

Temp: afebrile

Bp:130/80 mm Hg

Rr: 18 cpm

Pr:82 bpm

Systemic examination:

Cvs: S1 S2 heard, No murmurs

CNS: hmf+

Rs: blae +

P/a: soft, non tender

[16/06, 10:51] Harika 2k18 Junior: Op no - 20230623578

A 50 year old female patient came to OPD with complaints of Burning micturition since 2 months.

Fever since 2 months.

Patient was tested with IgM Typhoid positive 1 month ago .

Patient was diagnosed with DM 3 months back on regular medication -Metformin 500 mg

Patient is a k/c/o Hypothyroidism since 3 years and on medication -Thyronorm 75 mcg.

On Examination:

Pt is c/c/c

Temperature -afebrile

BP- 120/80 mmHg

Pr-80bpm

Rr-16 cpm

Systemic examination:

Cvs- S1,S2 heard no murmurs

Rs-BAE+ NVBS Heard

P/A - Soft and nontender

Cns- HMF +.

[16/06, 10:53] Tejaswi 2k18 Surgery Unit 6: Op No: 20230623567

C/o heachache ( on and off) with holocranial throbbing type since 1 year .

Not associated with photophobia, phonophobia,

vomitings and nausea and no diurnal variation

Past History: N/k/c/o dom, asthma, htn, epilepsy

General examination:

No pallor ,icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.

Temp: afebrile

Bp:100/70 mm Hg

Rr: 18 cpm

Pr: 100bpm

Systemic examination:

Cvs: S1 S2 heard,No murmurs

CNS: hmf+

P/a: soft, nontender

Rs: blae+

[16/06, 11:01] Harika 2k18 Junior: Opno- 20230623570

A 33 year old male patient presented to OPD with complaints of pain in Left iliac fossa since yesterday morning .

C/o Burning Sensation in epigastric region and hypogastric region since yesterday morning .

H/o Vomitings 2 episodes yesterday

non projectile,food as content,non foul smelling and non blood stained .

H/o outside food consumption on 13/6/23 evening .

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

On Examination:

Pt is c/c/c

Temperature -afebrile

BP- 110/70mmHg

Pr-80bpm

Rr-19cpm

Systemic examination:

Cvs- S1,S2 heard no murmurs

Rs-BAE+ NVBS Heard

P/A - no local rise of temperature

Tenderness present in the Epigastric and Hypogastric region,left iliac region.

Cns- HMF +.

[16/06, 12:16] Sowmya Bharadwaj: Op no: 20230624459

A 40 year old female came with c/o body pains since one year

C/o chest pain since 1 year, non-radiating type

No aggravating and relieving factors.

Not associated with palpitations, orthopnea, PND

Not associated with fever, cough, cold, loose stools, vomitings.

H/o ? Heart surgery? (Repair of congenital defect 12 years ago)

K/c/o hypothyroidism since 3 months on regular medication (Tab Thyronorm PO/OD )

N/K/C/O DM, hypertension,asthma, epilepsy, TB, CVA, CAD.

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy , edema

Vitals-

Temperature: Afebrile

PR: 72 bpm

BP: 90/60 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[16/06, 12:18] Sreelekha ❤: Op no: 20210526147

A 67 year old male came with c/o B/L knee pain since 1 year

SOB ( grade 2 mMRC ) since 3 months

Not associated with chest pain, palpitations, orthopnea, PND

Not associated with fever, cough, cold, loose stools, vomitings.

K/c/o Hypertension since 1 year on regular medication (unknown)

K/c/o diabetes mellitus since 1 year on regular medication (GLIMI M1 PO/OD).

N/K/C/O asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

VITALS:

Temperature: Afebrile

PR: 82 bpm

BP: 120/70 mmHg

SYSTEMIC EXAMINATION

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[16/06, 12:21] Sowmya Bharadwaj: Op no: 20210505192

A 64 year old male came with c/o swelling in both lower limbs since one year.

C/o decreased urine output since 1 week

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

No c/o with fever , abdominal pain, burning micturition.

H/o B/L inguinal hernia. Surgery done 10 years ago

K/c/o hypertension since 10 years on regular medication (Tab Amlodipine 5mg )

K/c/o hypothyroidism since 10 years on regular medication (Tab thyronorm 100 mcg PO/OD)

N/K/C/O DM, epilepsy, TB, CVA, CAD.

General examination -

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy.

Pedal edema of pitting type - grade 2 present

Vitals-

Temperature: Afebrile

PR: 74 bpm

BP: 110/70 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

The patient was advised for admission but was not willing.

[16/06, 15:21] Sowji: Op no: 20230625101

A 45 year old female came for general checkup.

K/c/o hypertension since 2 years on regular medication (Tab Telma 20mg for 1year) and after follow up with her regular doctor she was advised to use Tab Telma 40mg (since 1 month)

N/K/C/O DM, epilepsy, thyroid disorders, TB, CVA, CAD.

H/o Cataract surgery 1 year back .

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema.

Vitals:

Temperature: Afebrile

PR: 80 bpm

RR: 18cpm

BP: 150/100mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[16/06, 15:43] +91 81797 90837: Op no: 20230625114

A 47 year old female came with c/o Vomitings (3-4 episodes /day) from 5 days - Non-projectile, non-bilious, containing food particles, large volume.

C/o Dry cough since 5 days after vomiting

C/o Fever since 5 days ( Low grade, intermittent, relieved with medication)

C/o SOB (Grade III) since 5 days , increases with vomiting

No C/I Pain abdomen , loose stools, constipation

K/c/o hypertension since 10 days on regular medication (Unknown)

K/c/o DM since 10 days on medication (Tab Metformin 500 mg + Tab. Teneligliptin 20mg PO/OD)

N/K/C/O epilepsy, thyroid disorder,TB, CVA, CAD.

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 74 bpm

BP: 120/70 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , tenderness in Right iliac fossa

[16/06, 16:55] Sreelekha ❤: Op no: 20230624659

A 40 year old male came with c/o neck pain which is of dragging type and associated with headache in the occipital region since 2 months.

Headache relieved on its own without taking any medication.

H/o trauma to the head 2 months back. No h/o loss of consciousness, vomiting, ent bleed, seizures after the event.

N/K/C/O DM, HTN, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 76 bpm

BP: 120/70 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

The patient was advised for admission but they were not willing

17th June 2023

[17/06, 10:18] Srilakshmi: Op no: 20210214212

A 61 year old female came for follow up

K/c/o DM II since 15 years with retinopathy peripheral neuropathy

On INJ HAI SC/TID 6 UNITS

INJ NPH SC/ BD 8 UNITS

K/C/O HTN since 10 years

Tab Telma h Po /od

Tab met XL 12.5 mg Po /od

Came with c/o bloating, belching, regurgitation + nausea since 1 month

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 100 bpm

BP: 120/80 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

[17/06, 10:21] Dr. Rakesh biswas: What did you do and plan for him?

[17/06, 10:23] Srilakshmi: A 68 year old female came with c/o pain at the right hypochondrium since 1 month

H/o cholecystectomy done 1 yr ago

C/o bloating sensation after having food bitter taste after having food

Not a K/C/O HTN DM CVA CAD TB ASTHMA

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 68 bpm

BP: 110/70 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: tenderness + in right hypochondrium

[17/06, 10:25] Srilakshmi: As this patient had tenderness at surgical site, we advised her to get USG abdomen done

[17/06, 10:27] Srilakshmi: She complained of Bloating, belching and regurgitation so we are suspecting Acid peptic disesase and started her on T. Pantop. Patient was advised for admission but was not willing.

[17/06, 10:27] Meghana T: Op no 20230625857

A 44 year old female came to op with c/o chest pain since 1 month

Pin pricking sensations and dragging type of pain , duration - 1 to 2 hrs present even at rest associated with dragging sensation in Left upper limb, lower limb and neck

There is a H/o Palpitations, h/o weight lifting present

SOB + ,grade 2-3 (NYHA)

No h/o orthopnea, PND, cough, cold, fever

No h/o pedal edema

Chest pain not associated with food intake

N/K/C/O DM, HTN, asthma, epilepsy , cad, TB, thyroid abnormalities

Neck pain increases with movement of neck, associated with tingling and numbness

O/E

Patient is conscious, coherent, cooperative

Vitals:

Temp: afebrile

PR: 82 bpm

Bo: 140/90 mm hg

General examination:

Pallor - present

No signs of edema, icterus, cyanosis, clubbing lymphadenopathy

Systemic examination:

CVS : S1,S2 heard, no raised jvp

CNS-NFND

RS- BAE + NVBS +

P/A- Soft , non-tender

Tenderness present D4 -D6, no paraspinal stiffness

[17/06, 10:44] Meghana T: Op no 20230625435

A 38 year old female came with c/o localised left sided chest pain radiating to left upper limb with tingling sensation of the fingers since 3 days- continuous type

No c/o SOB, chest pain, orthopnea, Palpitations, PND

Patient usually sleeps on left lateral position

No h/o similar complaints in the past

Not a k/c/o DM, HTN , asthma, epilepsy, CAD

On examination:

Patient is conscious, coherent and cooperative

Vitals:

BP: 140/80 mm hg

PR: 96 bpm

Afebrile

Systemic examination:

CVS- S1 S2 +,no murmurs

CNS- NAD

RS- BAE+ NVBS+

C-spine :normal

No spinal tenderness

Range of movements - normal

Reflexes- normal

Pain increases with neck movements

[17/06, 10:45] Dr. Rakesh biswas: Please let us know what is being done for each of these patients and under who's supervision

[17/06, 11:24] Srilakshmi: Op no: 20230625968

A 42 year old female came with c/o shortness of breath since 4 days in ordinary activity (grade II mmrc)

No orthophnea PMD PEDAL odema chest pain palpitations

K/O/C DM II SINCE 1 YEAR IS ON TAB GLIMIPRIDE 2 MG + METFORMIN 500MG + PIOGLITAZONE 15 MG

NOT A K/C/O HTM CVA TB ASTHMA THYROID DISORDER

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 68 bpm

BP: 138/80 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

PT was ADVISED for admission but is not willing

[17/06, 11:30] Srilakshmi: Op no: 20230626386

A 42 year old female came with c/o bloating sensation of the abdomen since 2 to 3 minths

Bloating after food +

Belching +

Regurgitation of food +

K/C/O thryroid disorder since 10 uears on 10 mcg po bd

Not a known case of HTN DM CVA CAD TB ASTHMA

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 86 bpm

BP: 110/80 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[17/06, 11:48] Srilakshmi: Op no: 20230626418

A 55 year old male came with c/o shortness of breath on ordinary activity grade II mmrc since 1 month

C/O pedal odemapitting type upto knees since 1 month

Initally on and off

Then continous since 5 days

No c/o decreased urine output palpitations

K/C/O HTN since 3 yeats on regular medication tab telma 40 mg po od

Not a known case of DM CVA CAD TB ASTHMA

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 86 bpm

BP: 110/80 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[17/06, 11:54] Srilakshmi: Op no: 202306266462

A 5O year old male came with c/o belching since 1 minth aggravated since 2 days and on having tangy food

Bloating +

Belching +

K/C/O DM II since 3 years on regular medication

Not a known case of HTN DM CVA CAD TB ASTHMA

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 86 bpm

BP: 110/80 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

TREATMENT

1) TAB RAZO D 40 MG PO OD FOR 14 DAYS

2) SYP SUCRAFYL 10 ML PO TID

[17/06, 22:42] Lohith Sir Gen Med: 20 cases seen sir 7 admission

19th June 2023

[19/06, 09:27] Stimita2: Op no :20230500996

C/0 generalized weakness since 7 days

H/o vomiting since 5 days

(2-3 episodes) non projectile, biliary,watery with food particles as content.

H/o constipation since 15 days.

H/o loss of appetite,burning sensation in epigastrium

Past hist:

Chronic alcoholic since 25 yrs

K/c/o DM and HTN since 8 yrs.( on regular medication T.Telma 40 mg OD ,T. Teneglyptin 20 mg+ metformin 500 mg)

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 102 bpm

BP: 110/70 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 09:30] Dr. Rakesh biswas: What is your plan and strategy to help this patient further?

Who are the SR and JR guiding you in opd for this patient

[19/06, 09:39] Vibh: Op no: 20210111761

A 33 year old male came, k/c/o diabetes since 1 year (on Tab METFORMIN 500mg OD) came for regular follow up.

He has no h/o polyuria, polydipsia, polyphagia.

No h/o tingling sensation in hands and feet

No h/o giddiness, palpitations, tremors

No h/o burning micturition

N/K/C/O HTN, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 76 bpm

BP: 130/90 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[19/06, 09:46] Dr. Rakesh biswas: Share his clinical images of visceral fat and lateral view of biceps

Is he DM2 or MODY?

[19/06, 10:21] Stimita2: Sir, He is a chronic alcoholic since 25 years and LFT was deranged which was done 5 days ago.so suspecting Alcoholic liver disease.

[19/06, 10:25] Stimita2: Op no : 20230500998

C/o easy fatiguability and generalized weakness since 2 months

No H/o SOB,palpitations,

No h/o blood loss

Not a known case of HTN,DM CVA CAD TB ASTHMA EPILEPSY

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 78 bpm

BP: 120/80 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 10:35] Vibh: He has family history of DM, and is not obese sir. Most likely MODY

[19/06, 10:35] Vibh: Op no : 20230500998

C/o nocturia since 2-3 months

C/o increased thirst since 6 months

Tingling sensation in hands and feet since 1 month

No h/o polyphagia

No h/o urinary urgency, burning micturition

K/c/o DM2 since 2 years on tab glimi M1 OD

K/c/o HTN since 5 years on tab atenolol 50mg OD

Not a known case of CVA CAD TB ASTHMA EPILEPSY

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 100 bpm

BP: 140/90 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 11:01] Stimita2: Op no :20230424430

C/0 weight loss since 1 rear

H/o loss of appetite since 1 year

No H/o pain abdomen,vomiting,loose stools, constipation

No H/o cough,evening rise of temperature

No c/o chest pain,palpitations,SOB

Menstrual history-normal

Not a known case of HTN DM CVA CAD TB ASTHMA

K/c/o hypothyroid since 6 months.

(On tab. Thyronorm 25mcg , not taking medication since 1 month)

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 105 bpm

BP: 100/70 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 11:15] Stimita2: Op no: 20230628685

C/o stomach pain since 5 days

Pain increases after intake of food.

No H/o nausea,vomiting

No similar complaint in the past

Not a known case of HTN DM CVA CAD TB ASTHMA

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 68 bpm

BP: 110/80 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 11:17] Vibh: Op no : 20230500998

C/o tingling and numbness of both lower limbs since 3 days

No h/o SOB, palpitations, chestpain

No h/o polyphagia, polyuria, nocturia

No h/o fever, cough, burning micturition, pain abdomen

Not a known case of HTN,DM CVA CAD TB ASTHMA EPILEPSY

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 86 bpm

BP: 120/80 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 11:22] Stimita2: Op no : 20230628210

C/o abdominal distension and bloating since 10 days.

A/w pain abdomen, increased after food intake

No H/o belching, burning sensation, chest pain,sob

H/o constipation since 10-15 days.

Not a known case of HTN DM CVA CAD TB ASTHMA

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 72 bpm

BP: 110/80 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 11:30] Vibh: Op no : 20230501024

C/o facial puffiness since 1 week

C/o pedal edema since 1 week

Pedal edema pitting type, extending until ankle

H/o SOB since 4 days, grade 2 NYHA

No h/o decrease in urinary output, burning micturition

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

Not a known case of HTN,DM CVA CAD TB ASTHMA EPILEPSY

General examination:

Patient is conscious, coherent and cooperative.

Pedal edema + grade 2 pitting type

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy

Vitals-

Temperature: Afebrile

PR: 76 bpm

BP: 120/70 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 11:36] Vibh: Op no : 20230628216

A 45 year old female came with c/o neck pain since 1 year

Non radiating type, aggravated on sleeping, no relieving factors

No tingling sensation

Not a known case of HTN,DM CVA CAD TB ASTHMA EPILEPSY

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, pedal edema

Vitals-

Temperature: Afebrile

PR: 65 bpm

BP: 120/70 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 11:44] Vibh: Op no: 20210526472

A 43 year old female came with c/o headache since 1 year

Intermittent episodes, 1-2 times a week, lasting 6-8 hours

Photophobia +

Phonophobia +

Nausea before headache +

No h/o lacrimation before or during headache

N/K/C/O HTN, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 72 bpm

BP: 110/90 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[19/06, 11:51] Stimita2: Op no : 20210421302

32years old male came with fever on and off and generalized weakness since 3 days.

Loss of appetite since 2 days.

Fever not relieved on medication.

No h/o burning micturition, vomitings, loose stools, pain abdomen

Not a known case of HTN DM CVA CAD TB ASTHMA

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 80bpm

BP: 110/60 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 12:11] Vibh: Op no: 20210109283

A 55 year old male came with c/o giddiness 1 episode yesterday

No c/o loss of consciousness, seizures, deviation of mouth

No c/o chest pain, SOB, palpitations, orthopnea, PND

No c/o polyphagia, polydipsia, polyuria, burning micturition, pain abdomen

No c/o loss of weight, loss of appetite

Occasional alcoholic since 30 years

Non smoker

N/K/C/O HTN, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

Moderately built and moderately nourished

Temperature: Afebrile

PR: 80 bpm

BP: 110/70 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[19/06, 12:42] Vibh: Op no: 20230628838

A 36 year old female came with c/o headache since 1 month

Intermittent in nature, lasting for 2-3 hours

Photophobia absent

Phonophobia absent

Nausea, vomiting absent

No c/o cold, cough, fever

No h/o lacrimation before or during headache

N/K/C/O HTN, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 82 bpm

BP: 100/70 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[19/06, 14:54] Stimita2: Op no: 20230629167

26yrs old female came with the c/o neck pain and headache since 1 month, insidious in onset, intermittent,no aggravating or relieving factors.

No H/o nausea,vomiting, photophobia,phonophobia,no restrictions of movements.

No recent h/o fever, cold, no h/o lacrimation before or after headache.

Not a known case of HTN DM CVA CAD TB ASTHMA

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 98 bpm

BP: 110/60 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER

[19/06, 15:00] Vibh: Op no: 20230629191

A 38 year old male came with fever with body pains since 1 week

Fever was intermittent, low grade, not associated with chills or rigors

H/o lower back pain since 1 year for which he takes medication

N/K/C/O HTN, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

H/o renal stones 20 years ago

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 96 bpm

BP: 120/70 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[19/06, 15:05] Stimita2: Op no: 20230629157

32 years male patient came with complaints of burning sensation 30 minutes after consumption of meal since 15 days

Aggravated with spicy foods ,relieves on rest

Not associated with chest pain,SOB, palpitations

Complains of pain in bilateral lower limbs since four days, dragging type of pain,

No history of trauma

Not a k/c/o HTN ASTHMA DM CVA CAD TB EPILEPSY

On examination

Pt is c/c/c

No pallor icterus cyanosis clubbing lympadenopathy

Vitals:

Temperature - afebrile

PR: 72 bpm

BP: 120/70 mm hg

Systemic examination

CVS S1 s2 heard no murmurs

RS BAE +

P/A soft NT

CNS NFND

[19/06, 22:38] Dr. Rakesh biswas: Another patient seen in opd today (also in ward) and not admitted 👇

[6/19, 3:31 PM] Rakesh Biswas: Share the EEG video in the group

[6/19, 5:36 PM] Anonmized PG from somewhere: The final copy will be given to them after neuro sir see the eeg sir

[6/19, 5:44 PM] Rakesh Biswas: Have they left?

[6/19, 6:31 PM] Anonmized PG from somewhere: Spoke to the attender told them after we take opinion from neurologist regarding the eeg and his condition sir

[6/19, 7:31 PM] Rakesh Biswas: What about your learning on the EEG?

[6/19, 8:52 PM] Anonmized PG from somewhere: Eeg records a spike if there is. Any episode of seizure . But here the patient is not having any seizure activity sir so eeg may turned be out normal

[6/19, 9:12 PM] Rakesh Biswas: Have you read about interictal EEG and it's role in diagnosis?

What's the diagnostic sensitivity specificity for interictal EEG like your patient had?

20th June 2023

[20/06, 09:57] Vishnubharath: Op no: 20230629528

A 45 year old female came with c/o cough with mucoid sputum since 10 days,intermittent type

Complaints of low grade fever not associated with chills or rigors

N/K/C/O HTN, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 86 bpm

BP: 110/70 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[20/06, 10:05] Rohith Somani: 20230619842

43M

K/c/o hypothyroidism since 4yrs and on medication tab.thyronorm 150mcg po/od came for follow up

T3:0.99

T4:12.8

TSH:0.59

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

O/E

Cvs-s1s2+

Rs-NVBS,BAE+

CNS-NFND

P/A:soft, nontennder

[20/06, 10:05] Vishnubharath: Op no : 20230629526

58 year old male came with complaints of abdominal discomfort and bloating since 10 days.

SOB on sitting/on exertion

No H/o belching, burning sensation, chest pain

No H/o constipation

K/c/o chronic liver disease since 10 years and not on medication

Not a known case of HTN DM CVA CAD TB ASTHMA

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 82bpm

BP: 110/70 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: SOFT, NON TENDER,NO SHIFTING DULLNESS,NODISTENSION

[20/06, 10:15] Vishnubharath: Op no: 20230629532

A 70 year old male came with complaints of body pains since 10 days

Low grade fever since 10 days not associated with chills or rigors

No complaints of vomitings,loose stools,sob,chest pain,palpitations

K/c/o HTN,DM-ll on regular medication

(Tab Amlodipine5mg + Atenolol50mg)

(Tab voglibose 0.2mg,Glimiperide2mg and metformin500mg)

K/c/o pulmonary TB-5 years ago and used medication

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 76 bpm

BP: 100/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[20/06, 10:46] Vishnubharath: Op no: 20210520425

A 50 year old male came, k/c/o seizures since 20years and not on medication came with H/O seizures yesterday evening

GTCS seizures with the history of tongue bite, froathing(for 10 min) and loss of consciousness

No involuntary micturition, and defecation

Patient had history of seizures once in every year

Patient had history of low-grade fever since 3-4 days and c/o giddiness

N/K/C/O HTN,DM,asthma, thyroid disorder, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 86bpm

BP: 100/60 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Advised for admission but patient not willing for admission

[20/06, 10:59] Srinidhi Kims: Op no:20230629544

A 55yr old male pt came with complaints of right upper limb and lower limb weakness since 3 days

Deviation of angle of mouth towards left since 3 days

H/o passage of urine involuntarily since 3 days

Known case of Cva to hemiparesis 3 yrs back

Used some herbal medication for the same

K/c/o HTN since 5 yrs -on medication tab.telma 40mg Po/OD

N/k/c/o asthma,DM,cvd,thyroid disorders,TB,epilepsy

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:150/60mmhg

PR: 82

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft,non tender

[20/06, 11:00] Srinidhi Kims: OP No: 20230630025

A 60yr old male patient had A/H/o fall and trauma to head yesterday night

Pt complains of giddiness after fall after yesterday night

K/c/o HTN since 10 yrs on telma 40mg

DM type II since 10 yrs on OHA metformin 100 mg

N/k/c/o Tb,cva,cad,asthma,epilepsy

General examination:

Pt is consious,coherent,cooperative

Temperature:afebrile

BP:120/70mmhg

PR:76

CVS:S1s2 heard, no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

[20/06, 11:03] Vishnubharath: Op no: 20210308073

A 44 year old female came, complaints of burning micturition since 10 days and low grade fever,intermittent type

Fever not associated with chills and rigors

No c/o cold,cough,vomitings,loose stools

N/K/C/O HTN, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 84bpm

BP: 120/80 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[20/06, 11:06] Srinidhi Kims: OP No: 20230629993

A 16yr old male cane with complaints of pain in knee joint,shoulder joint, wrist joint,ankle joint and in neck region since 1 month

H/o fever 20 days back

Pain in Epigastric region and chest tightness since 3 days

C/o difficulty in breathing after walking for about 500 meters

No c/o vomitings,loose stools

N/k/c/o HTN,DM ,Tb,cva,cad,asthma,epilepsy

General examination:

Pt is consious,coherent,cooperative

Temperature:afebrile

BP:120/70mmhg

PR:76

CVS:S1s2 heard, no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

[20/06, 11:24] Vishnubharath: Op no: 2021031669

A 42 year old female came, complaints of bloating and belching since 5 days which is aggravated by taking tangy or spicy foods

C/o low backache since 3 days which is aggravated on bending forward and relieved on taking rest and non radiating to lower limb

No c/o cold,cough,vomitings,loose stools

N/K/C/O HTN, DM,asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

Pallor:+

No cyanosis,clubbing,icterus,lymphadenopathy

Temperature: Afebrile

PR: 92bpm

BP: 120/80 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , mild tenderness around the umbilicus

Diagnosis:?APD and Low backache

Advised for admission but patient now willing for admission

[20/06, 11:27] Dr. Rakesh biswas: What was done for her?

[20/06, 11:28] Dr. Rakesh biswas: What was done for her?

[20/06, 11:29] Dr. Rakesh biswas: What was done for him?

[20/06, 11:31] Dr. Rakesh biswas: What would you have done for him after admission? What would be your plan? Please mention the SR and JR guiding you there in the opd

[20/06, 11:32] Dr. Rakesh biswas: What would you have done for him after admission? What would be your plan? Please mention the SR and JR guiding you there in the opd

[20/06, 11:59] Srinidhi Kims: Advice for physiotherapy

evaluate the pt for the recurrent stroke

Patient was advised for admission but was not willing

[20/06, 12:08] Srinidhi Kims: Would have plotted a fever chart and try to understand the relation between fever spikes and the joint pains

But currently he is afebrile

[20/06, 12:22] Vishnubharath: She complained of Bloating, belching and regurgitation so we are suspecting Acid peptic disesase and started her on T. Pantop.Patient was advised for dietary modifications . Patient was advised for admission but was not willing.

[20/06, 12:28] Srinidhi Kims: For recurrent stroke we’d like to rule out any association with HTN (BP monitoring and appropriate medication ) and Association between metabolic syndrome and stroke is ruled out

statins and lipid lowering agents and anti platelets like clopidogrel can be given as a prophylactic measure

[20/06, 12:46] Srinidhi Kims: OP No: 20230436417

A 50yr old female came with complaints of whitish colour discharge in urine since yesterday night

C/o burning micturition since 1 day

C/o fever 4 days back

She has H/o recurrent UTI (3 episodes)

K/c/o DM -since 12 yrs -is on insulin

N/k/c/o HTN,Tb,cva,cad,asthma,epilepsy

General examination:

Pt is consious,coherent,cooperative

Temperature:afebrile

BP:130/70mmhg

PR:82

CVS:S1s2 heard, no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Diagnosis:B/L pyelonephritis with right hydroureteronephrosis

Pt was advised for admission and is willing to get admitted

Dr.nikitha(SR)

Dr.pavan(JR)

[20/06, 15:07] Vishnubharath: Op no: 20230631061

A 65 year old female came, complaints of headache since 3 months

Headache relieves on medication and relapses back

Headache associated with giddiness intermittent episodes

No c/o nausea,vomitings,blurring of vision

K/c/o of HTN since 3 years and on medication Tab.Amlodipine 5mg

N/K/C/O DM,asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

No pallor,cyanosis,clubbing,icterus,lymphadenopathy

Nystagmus: -

Rombergs: -

Temperature: Afebrile

PR: 92bpm

BP: 130/80 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

[20/06, 15:09] Rohith Somani: 20230631094

40yr/f

clo pedal edema 3 Mouth b/l( first 2 months intermittent, later became continuous for last 1 month)till ankle

h/o facial puffiness 3 days ago. No h/o SOB. Palpitations, chest pain

No h/o fever, cough, cold h/o decreased urine output 10 days.

No h/o burning micturition.

Not a k/c/0 HTN, DM, thyroid disorder, CAD, CVA, Epilepsy,Asthma

Cvs-s1s2+

Rs-NVBS,BAE+

CNS-NFND

P/A:soft, nontennder

[20/06, 15:35] Rohith Somani: 20230630702

28yr F

Known case of hypothyroidism since three years on medication,thyronorm 35.7 µGM

Complains of cold cough fever generalised weakness since three days

Fever, low-grade not associated with chills and rigors associated with decreased appetite

Cough with sputum,yellow in colour, scanty, non-blood stained

Not known case of DM,HTN, asthma,epilepsy

O/E

Pt is c/c/c

Rs:NVBS,BAE+

CVS:s1s2+,no murmurs

P/A-soft,nontender

CNS-NAD

[20/06, 15:36] Vishnubharath: Op no: 20210514560

A 42 year old male came, complaints of tingling in right upper limb since 1 month

Burning micturition since 1 month and not associated with decreased urinary output,facial puffiness,pedal edema

N/K/C/O HTN, DM,asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

No pallor,cyanosis,clubbing,icterus,lymphadenopathy

Temperature: Afebrile

PR: 82bpm

BP: 120/80 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A:soft,non tender

Advised for admission but patient not willing for admission

[20/06, 15:45] Rohith Somani: 20230631139

38yr F

c/o abdominal pain since 3days, c/o loin pain since 1 week.

Abdominal pain, squeezing type, nonradiating, nonprogressive, no h/o

aggravating on relieving factor

Associated with loss of appetite since 5days

No H/o belching, regurgitation

No h/0 fever, cough, cold.

H/0 burning micturition 1 episode.

Not k/c/o DM,HTN,asthma,TB,epilepsy,CAD

O/E

Pt is c/c/c

CVS-s1s2+

CNS-NAD

RS:BAE+,NVBS

P/A

Rt hypogastric,umbilical tenderness present

BS+

Advised for admission but patient is not willing

Dr.Nikitha(SR)

Dr.pavan(JR)

[20/06, 15:46] Vishnubharath: Op no: 20210511109

A 39 year old female came, complaints of neck pain since 2 days

H/o giddiness since 2 days

Complaints of fever which is low grade and intermittent type and not associated with chills and rigors

Patient took some unknown medication for headache but headache not relieved

Patient had h/o burning micturition since 2-3 days

And pain in the abdomen and loose stools since 2 days

No c/o nausea,vomitings,blurring of vision

N/K/C/O HTN,DM,asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

No pallor,cyanosis,clubbing,icterus,lymphadenopathy

Temperature: Afebrile

PR: 82bpm

BP: 110/70 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Patient advised for admission but patient not willing for admission

Dr.Nikitha (SR)

Dr.Pavan(JR)

[20/06, 16:00] Vishnubharath: 20230630002

38 year old male

clo pedal edema since 20 days

Pedal edema is pitting type ,grade-2

No h/o facial puffiness.No h/o SOB. Palpitations, chest pain

No h/o fever, cough, cold

No history of decreased urine output and burning micturition

Not a k/c/0 HTN, DM, thyroid disorder, CAD, CVA, Epilepsy,Asthma

On examination:

Patient is conscious, coherent and cooperative.

No pallor,cyanosis,clubbing,icterus,lymphadenopathy

Temperature: Afebrile

PR: 84bpm

BP: 130/80 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Patient advised for admission but patient not willing for admission

Dr.Nikitha(SR)

Dr.Pavan(JR)

[20/06, 16:08] Rohith Somani: 20230630138

25yr F

pt had c/o swollen foot Since 3 days

pt come for general health checkup and joining as a warden in ladies hostel.

Not k/c/o DM,HTN,thyroid ,asthma,TB,epilepsy

(H/O SOB present mmc grade 3)

Hb-3.5

TLC-4,500

Plt:1.5lakh/mm3

O/E

CVS-s1s2+

RS:BAE+

Patient is advised to admit but she want to admit tomorrow

Dr.Nikith(SR)

Dr.Pavan(JR)

[20/06, 16:17] Vishnubharath: Op no: 20230631141

A 36 yearold female k/c/o anaemia with blood loss due to ? Right ovarian cyst

C/o sob since 2 months Grade-3 no aggravating and relieving factors

Not associated with palpitations ,chest pain, orthopnea ,PND

No h/o pedal edema

C/o vomitings since two months, intermittent after taking food non-bilious non-projectile around 1 to 2 episodes per week

C/o throat pain with dysphagia since two months

C/o cough since four months not associated with sputum

No H/O fever

H/o belching with regurgitation

Since two years and on medication, tab.Rantac for 1and half year and stopped 6 months back

K/c/o GERD with anaemia

N/K/C/O HTN,DM,asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

Pallor: +

No cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 78bpm

BP: 110/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Investigations on 30/5/23

Blood urea:113

Serum creatinine:7.7

Serum albumin:3.9

Hb:6.5gm/do

Usg:B/L grade-1 RPD

Patient is advised to admit but not willing for admission

Dr.Nikitha(SR)

Dr.Pavan(JR)

[20/06, 16:20] Rohith Somani: 20230630120

24yr F

Complaint of headache since one year on and off type

Aggravated two days back

Intermittent in nature

Associated with neck pain not associated with nausea

Not a known case of HTN,DM, epilepsy, asthma, CAD ,thyroid disorders

O/E

Pt is c/c/c

CVS-s1,s2+

RS-BAE+

P/A-soft,non tender

CNS-NAD

Patient is advised for admission, but not willing to admit

Dr Nikitha(SR)

Dr Pavan (JR)

[20/06, 16:38] Srinidhi Kims: Op no:20230631125

A 70yr old male pt came with complaints of right lower limb swelling near ankle since 3 days

C/o B/L lower limb knee pain(left>>Rt) since 3 days

H/o hip pain since 2 yrs

K/c/o HTN since 3 yrs- on medication tab.atenolol 25mg po/od

K/c/o DM II since 5 yrs- on metformin 500mg + glimileride 1mg

N/k/c/o asthma,cvd,thyroid disorders,TB,epilepsy

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:130/80mmhg

PR: 82

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft,non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.pavan (JR)

[20/06, 16:42] Srinidhi Kims: Op no:20230631121

A 60yr old female pt came with complaints of low grade fever-intermittent,evening rise of temperature since 5 days

H/o burning micturition +

C/o bloating and belching after having food

C/o body pains

No c/o cold,cough,rashes

K/c/o HTN since 10 yrs- on medication tab.telma 40mg

K/c/o DM II since 12. yrs- on glimileride 1mg

N/k/c/o asthma,cvd,thyroid disorders,TB,epilepsy

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:90/60 mmhg

PR: 76

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft,non tender

Pt was advised for admission but is not willing to admit

21st June 2023

[21/06, 10:54] +91 92906 89343: Op no. 20210600541

A 74 year old female came In to the opd with the complaints of fever on and off (intermittent) since 1 month not associated with chills, rigors relieved with medications

No vomiting, no loose stools, no pain abdomen, no SOB, no burning micturition

History of similar complaints 6 months ago diagnosed to have thyphoid and treated symptomatically

K/c/o DM since 10 years on NPH 10U - 0 -10U

C/O polyuria, polydypsia,polyphagia,

nocturia

No burning of feet or palms

K/C/O HTN since 20 years on medications (unrecalled)

N/K/C/O Asthma, CAD, TB, Epilepsy,Thyroid abnormalities

Associated with weight loss from 90kg to 74kgs in 6 months , pedal edema present grade II pitting type on and off

No SOB , No facial puffiness , no orthopnea, no abdominal distension

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 72bpm

BP: 120/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

[21/06, 10:56] Dr. Rakesh biswas: What would you do for her after admission? What would be your plan? Please mention the SR and JR guiding you there in the opd

[21/06, 12:07] Preity: Op no. 20210631091

A 22 year old female came to the opd with the complaints of generalised weakness since 2 months, easy fatigability since 2months.

No H/O fever, cough, shortness of breath, palpitations.

Not a K/c/o DM, HTN, thyroid, epilepsy

H/O blood transfusion 2 years ago - 2 units

On examination:

Patient is conscious, coherent and cooperative.

Pallor - present

No cyanosis, clubbing, icterus, edema.

Temperature: Afebrile

PR: 94bpm

BP: 100/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Patient adviced for admission but is not willing.

[21/06, 12:17] Preity: Op no. 20210328179

A 42 year old female came to the opd with the complaints of Shortness of breath(even during talking) since 20 days and cough since 20 days.

H/o Fever (on and off) since 20 days.

Fever - high grade, intermittent(present during nights), not associated with chills and rigors, relieved with medication.

Shortness of breath - Grade 3, no seasonal or diurnal variation. No H/o wheeze.

Cough - Productive, scanty, watery consistency, present more during day, associated with retrosternal chest pain which is non radiating.

No H/O loose stools, pain abdomen, vomitings.

Not a K/c/o DM, HTN, thyroid, epilepsy

On examination:

Patient is conscious, coherent and cooperative.

Pallor - present

No cyanosis, clubbing, icterus, edema.

Temperature: Afebrile

PR : 74bpm

BP : 110/70mmHg

RR : 24cpm

CVS : S1 S2+, no murmurs

CNS : NAD

RS : BAE+ NVBS+

P/A : soft , non tender

Patient adviced for admission but is not willing.

DR.ZAIN (SR)

DR. PAVAN (PG2)

[21/06, 12:26] Preity: Op no. 20230632448

A 45 year old female came to the opd with the complaints of chest pain on left side since 1 year.

Chest pain - pricking type, radiating to left hand, associated with palpitations, excessive sweating, giddiness, mild shortness of breath on exertion.

No H/O burning micturition, decreased urine output

Not a K/c/o DM, HTN, thyroid, epilepsy, CVA.

Family h/o - Father died of a heart attack.

On examination:

Patient is conscious, coherent and cooperative.

Pallor - present

No cyanosis, clubbing, icterus, edema.

Temperature: Afebrile

PR : 76bpm

BP : 100/60mmHg

RR : 18cpm

CVS : S1 S2+, no murmurs

CNS : NAD

RS : BAE+ NVBS+

P/A : soft , non tender

Patient adviced for admission but is not willing.

DR.ZAIN (SR)

DR. PAVAN (PG2)

[21/06, 12:35] Preity: Op no. 20230632507

A 50 year old female came to the opd with the complaints of back ache since 4 months (radiating to both legs), giddiness since 1 day, neckpain since 1 day (radiating to shoulder), headache since 1 day, Shortness of breath since 1 day (Grade 3).

H/O palpitations since 1 day, BP was 180/100mmhg yesterday at 4pm when checked by local doctor.

No h/o Fever, cough, burning micturition

Not a K/c/o DM, HTN, thyroid, epilepsy, CVA.

On examination:

Patient is conscious, coherent and cooperative.

Pallor - present

No cyanosis, clubbing, icterus, edema.

Temperature: Afebrile

PR : 84bpm

BP : 110/70mmHg

RR : 18cpm

CVS : S1 S2+, no murmurs

CNS : NAD

RS : BAE+ NVBS+

P/A : soft , non tender

Patient adviced for admission but is not willing.

DR.ZAIN (SR)

DR. PAVAN (PG2)

[21/06, 12:37] +91 92906 89343: Op no. 20210600541

A 75 year old female came In to the opd with the complaints of swelling in both lower limbs and face since 1 month associated with walking and prolonged sitting not reduced with rest

Grade II pitting type pedal edema

Associated with decreased urine output

SOB grade II

K/C/O DM since 20 years on amlodipine 5mg

HTN since 20 years on metformin 500mg + glimipride 1mg

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 112bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr Zain SR

[21/06, 12:46] +91 92906 89343: A 19 year old male came to opd with c/o of chest tightness (sternum) on bending forward associated with chest pain (on and off)

Everyday once or twice on sitting or changing position ,

relieved by extending spine / stretching , Intermittent since 1 year

No palpitation, No SOB

N/K/C/O HTN, DM, asthma, Epilepsy, asthma

H/O tap in right lung 1.5 liter fluid drained

?community acquired pneumonia

Medications (unrecalled) taken for 3 months

? TB

On examination:

Patient is conscious, coherent and cooperative.

NoPallor,cyanosis,clubbing,

icterus,

Temperature: Afebrile

PR: 78bpm

BP: 90/80 mmHg

Sternal tenderness present

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Zain (SR)

Dr.Pavan(PG2)

[21/06, 12:47] +91 92906 89343: Op no. 20230632395

48 year old female came to opd with c/o SOB MMRC II since 20 days

No orthopnea, Paroxysmal nocturnal dyspnea

Facial puffiness since 20 days

N/H/O chest pain, palpitation , pedal edema.

N/H/O vomiting , decreased urine output

K/C/O DM type II since 4 years on tab

GLIMI M PO/OD

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 88bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Zain (SR)

Dr.Pavan(PG2)

[21/06, 13:01] +91 92906 89343: OP NO. 20210314513

24 year old female came to the opd with c/o headache since 3 days

C/O pain on left perital region

C/O giddiness (rotational)

No variation with position change

No hearing loss or tinnitus

N/H/O aura, photophobia, photophonia

H/O trauma to head 4 years ago

(CT scan done - normal)

N/K/C/O HTN, DM, CAD, Thyroid , seizures

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 84bpm

BP: 100/60mmHg

RR: 18cpm

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Zain (SR)

Dr.Pavan(PG2)

[21/06, 13:07] Dr. Rakesh biswas: What would you do for her after admission? What would be your plan? Please mention the SR and JR guiding you there in the opd

[21/06, 14:47] +91 92906 89343: Op no. 20210428182

14 year old boy brought to opd by his mother with

C/o of chest pain since 2hrs, left sided radiating to abdomen

N/H/O SOB, palpitation, pedal edema, giddiness

Pain aggrevates after eating food

N/H/O fever, cough, vomiting

K/C/O seizures disorder used medication valproate 200mg PO/OD for 3 years

N/K/O HTN, DM

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 84bpm

BP: 100/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Zain (SR)

Dr.Pavan(PG2)

[21/06, 14:52] Preity: Op no. 20230632943

A 45 year old male came to the opd with the complaints of chest pain (Both sides).

Pain is more after eating food.

Complaints of abdominal tightness after eating food (bloated sensation).

Tingling and numbness all over hands and legs.

H/o loss of appetite.

H/o headache in the occipital region, not associated with aura or photophobia.

No h/o shortness of breath, Fever, pedal edema, palpitations, giddiness, cough, burning micturition, Vomitings.

Not a K/c/o DM, HTN, thyroid, epilepsy, CVA.

On examination:

Patient is conscious, coherent and cooperative.

No pallor, cyanosis, clubbing, icterus, edema.

Temperature: Afebrile

PR : 84bpm

BP : 120/70mmHg

RR : 18cpm

CVS : S1 S2+, no murmurs

CNS : NAD

RS : BAE+ NVBS+

P/A : soft , non tender

Patient adviced for admission but is not willing.

DR.ZAIN (SR)

DR. PAVAN (PG2)

[21/06, 15:05] +91 92906 89343: OP no. 20230632944

43 year old female came to opd with c/o chest pain since 1 week (bilateral)

Pain aggravated after taking food

N/H/O palpitation, pedaledema, giddiness, SOB

C/O headache B/L frontal

no aura, photophobia, photophonia

N/K/C/O HTN, DM, CAD, Thyroid abnormalities, seizures disorder

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 78bpm

BP: 100/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Zain (SR)

Dr.Pavan(PG2)

[21/06, 15:07] Preity: Op no. 20230632951

A 77 year old male came to the opd with the complaints of headache (bilateral frontal and temporal) since 10 days.

No h/o aura, photophobia.

Complaints of neckpain since one week radiating to bilateral upper limbs.

No h/o shortness of breath, Fever, pedal edema, palpitations, giddiness, cough.

Known case of CKD but not on any medication.

Not a K/c/o DM, HTN, thyroid, epilepsy, CVA.

On examination:

Patient is conscious, coherent and cooperative.

No pallor, cyanosis, clubbing, icterus, edema.

Temperature: Afebrile

PR : 82bpm

BP : 150/70mmHg

RR : 18cpm

CVS : S1 S2+, no murmurs

CNS : NAD

RS : BAE+ NVBS+

P/A : soft , non tender

Patient adviced for admission but is not willing.

DR.ZAIN (SR)

DR. PAVAN (PG2)

[21/06, 15:15] +91 92906 89343: Op no. 20230632874

39 year old female came to opd with the c/o rightsided headache since 1 year (on and off)

Aggravated by loud sound

Relieved on resting

Associated with aura

No photophobia

N/H/O giddiness, palpitation

N/H/O fever ,cough, vomiting, neck pain

N/K/C/O HTN,DM,CAD, Thyroid abnormalities, seizures disorder

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 84bpm

BP: 130/80mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Zain (SR)

Dr.Pavan(PG2)

[21/06, 16:41] Preity: Sir, the patient has a history of blood transfusion 2 years ago for her low hemoglobin. She has similar complaints again now. After admission I will take a detailed history of the patient, specifically the nutritional history and if required get investigations done and find the cause and treat accordingly.

22nd June 2023

[22/06, 09:45] Sowji Kims: Op :20230633232

50 F

C/o tingling and numbness of lower limbs since 2months.

C/o pain over the right shoulder since 2-3years-restriction of movements present, overhead abduction, tenderness present over the joint.

No H/o trauma

No H/o polyuria, polyphagia, polydypsia , nocturia

No c/o SOB, palpitations,chest pain, fever,pain abdomen, burning micturition.

Past history :k/c/o type DM Since 15 years and on medication (glimiperide 2mg,metformin100mg,voglibose 0.2mg)

Not k/c/o HTN, CVA CAD ,TB ,Asthma

On examination:

Pt is c/c/c

No pallor ,icterus, cyanosis ,clubbing, lympadenopathy

Bp-120/70mmhg

PR-100bpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :soft and non tender

CNS :NFND

Dr.Zain(SR)

Dr.Harika(PG1)

[22/06, 10:04] Sowji Kims: op no 20210202702

62/M

C/o tingling and numbness of pain of both upper and lower limbs since 2 months

C/o slurring of speech since 10days

K/c/o type 2 DM since 5years and on regular medication (Tab.glimi -M2)

K/c/o HTN since 5years and on regular medication ( Tab.Telma-H)

Not a known case of TB,asthma , epilepsy,CVA,CAD,thyroid disorders

O/E:

No pallor, icterus cyanosis, clubbing,lymphadenopathy, edema

BP-146/90mmhg

PR-98bpm

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 4/5. 4/5

REFLEXES:

B: 2 + 2+

T: 1+ 1 +

S: 1+ 1+

K: 2 + 2+

A: 1+ 1+

P: Flexor. Flexor

Sensory examination:

Graphaesthesia +

Stereognosis+

Joint proprioception

RT LT

6/10 4/10

Fine touch - absent in dermatomes L5-S1

Crude touch - absent in dermatomes L5-S1

Pain -present. Present

Dr.Zain(SR)

Dr.harika(PG1)

[22/06, 10:16] Jahnvi 2k18: Op:20210223776

41 F

C/o epigastric burn since 10 days

C/o headache associated with nausea,

Photophobia present

Phonophobia absent

No H/o fever , vomitings , burning micturition

K/c/o hypothyroidism since 8 years and on T. Thyronorm 100mcg

Weight loss (10kg) in last 1 year

No H/o constipation, cold intolerance,

Past history:

N/K/C/O: HTN, DM, TB, CAD, Asthma, Epilepsy.

O/E:

Pt is c/c/c

No pallor, edema , clubbing , cyanosis, lymphadenopathy

Afebrile

PR:76bpm

BP: 100/70 mmHg

CVS:S1S2+,no murmurs

No raised JVP

CNS: NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Dr. Zain(SR)

Dr. Harika(PG1)

[22/06, 10:30] Jahnvi 2k18: Op: 20230633238

60F

C/o pain over the right shoulder since 6 months , restriction of movements present, overhead abduction radiating to chest and abdomen

C/o palpitations

No H/o SOB , Orthopnea, PND

K/c/o CVA ( Right hemiparesis)

Since 3 years

on tab. Ecospirin-AV 75/20

Tab. Levipil 500mg

K/c/o DM since 15 years

on Tab. Metformin 500 mg

N/K/C/O: HTN, TB, CAD, Asthma, Epilepsy.

O/E:

Pt is c/c/c

No pallor, edema or exophthalmos

Afebrile

PR:73bpm

BP: 120/70 mmHg

CVS:S1S2+,no murmurs

No raised JVP

CNS: NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Dr. Zain(SR)

Dr. Keerthi (PG2)

[22/06, 10:45] Jahnvi 2k18: Op:20230633697

45/F

C/o pain in epigastric region since 4 days

Pricking type of pain

Non radiating , no palpitations, no sweating

Shortness of breath present since 4 days (grade-1)

No H/o Giddiness , fever , cold , cough , nausea, vomiting , loss of appetite

N/K/C/O: HTN, DM, TB, CAD, Asthma, Epilepsy.

O/E:

Pt is c/c/c

No pallor, edema , clubbing, cyanosis, lymphadenopathy

Afebrile

PR:78bpm

BP: 130/90 mmHg

CVS:S1S2+,no murmurs

No raised JVP

CNS: NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Dr. Zain(SR)

Dr. Keerthi(PG2)

[22/06, 10:47] Dr. Rakesh biswas: What's your diagnosis? How are you going to help this patient further?

[22/06, 11:13] Sowji Kims: Op :20230633234

40 F

C/o tingling numbness and electric shock like sensation in one half of body in right side since 2months, episodic,each episode lasting for 5-10min, 5-6 episodes / day

No h/o weakness of limbs

No h/o conjuntival congestion,no H/o LOC

No aggravating and relieving factors

Past history :k/c/o type DM Since 6 months andHTN since 1year on medication

Not k/c/o CVA CAD ,TB ,Asthma

On examination:

Pt is c/c/c

No pallor ,icterus, cyanosis ,clubbing, lympadenopathy

Bp-120/70mmhg

PR-78bpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :soft and non tender

CNS :NFND

Dr.Zain(SR)

Dr.Harika(PG1)

[22/06, 11:28] Sowji Kims: Patient is advised for admission, create pjar group and do the needful investigations .The patient is advised antiepileptic drugs and follow up of the patient has to be done sir

[22/06, 11:33] Sowji Kims: Op :20210303820

44 M

C/o neck pain since 1 year

C/o chest pain,non radiating, localized since 1year

C/o tingling sensation of left arm,left shoulder

C/o SOB , grade II ,Since 6months

C/o joint pains over the wrist joint, elbow joint,knee joint

Past history :

Not k/c/o DM ,HTN,CVA CAD ,TB ,Asthma

On examination:

Pt is c/c/c

No pallor ,icterus, cyanosis ,clubbing, lympadenopathy

Bp-110/80mmhg

PR-80bpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :soft and non tender

CNS :NFND

Dr.Zain(SR)

Dr.Harika(PG1)

[22/06, 11:39] Sowji Kims: Op :20210300003

42 F

C/o tingling and numbness of both upper and lower limbs since 3months .

Polyphagia+

No h/o Polydipsia, polyuria,nocturia.

C/o burning micturition since 1month

C/I low grade fever

No cough,cold, weight loss

No C/o SOB, Palpitations,chest pain

Past history :

Not k/c/o DM, HTN ,CVA CAD ,TB ,Asthma

On examination:

Pt is c/c/c

No pallor ,icterus, cyanosis ,clubbing, lympadenopathy

Bp-110/70mmhg

PR-70bpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :soft and non tender

CNS :NFND

Dr.Zain(SR)

Dr.Harika(PG1)

[22/06, 11:47] Sowji Kims: Op :2023064194

60 F

C/o SOB since 3days

Grade II ,orthopnea +,PND - absent

No h/o chest pain, increased sweating, Palpitations.

Past history :k/c/o CKD Since 2years with usg showing -grade II-III RPD changes-using Tab.lasix 20mg ,Tab.nodosis,Tab.calcitriol.

Not k/c/o DM, HTN ,CVA CAD ,TB ,Asthma

On examination:

Pt is c/c/c

No pallor ,icterus, cyanosis ,clubbing, lympadenopathy

Bp-110/68mmhg

PR-92bpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :soft and non tender

CNS :NFND

Dr.Zain(SR)

Dr.Harika(PG1)

[22/06, 12:01] Sowji Kims: Op :20230634234

43 F

C/o itching over the palms and soles since 1week

C/o generalized fatigue since 1week

C/o pain radiating down to the spine

Past history :

Not k/c/o DM, HTN ,CVA CAD ,TB ,Asthma

On examination:

Pt is c/c/c

pallor-present no icterus, cyanosis ,clubbing, lympadenopathy

Bp-120/80mmhg

PR-74bpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :soft and non tender

CNS :NFND

Dr.Zain(SR)

Dr.Harika(PG1)

[22/06, 12:21] Sowji Kims: Op :20230634300

60 M

C/o neck pain, radiating down the both shoulder since 6days.

No h/o fever,cough,cold

Noh/o SOB, Palpitations,chest pain

C/o burning micturition since 2weeks.

Past history :

K/c/o HTN since 3months on Tab.amiodipine 5mg

Not k/c/o DM, CVA CAD ,TB ,Asthma

On examination:

Pt is c/c/c

no pallor,icterus, cyanosis ,clubbing, lympadenopathy

Bp-130/90mmhg

PR-83bpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :soft and non tender

CNS :NFND

Dr.Zain(SR)

Dr.Harika(PG1)

[22/06, 14:55] Rohit Dharma: Op no 20210510489

56/M

C/o pain in epigastric region 1 week

Pain more after eating food

No radiation of pain

Shortness of breathe on excertion( grade 2)

No h/o pedal edema,loose stools, vomiting,pain abdomen

H/o occasional palpatation present

N/k/c/o hypertension asthma,epilepsy,CVA,CAP,Bronchial asthma,thyroid disorders

O/e

Patient was c/c/c

Vitals-

Temperature - afebrile

Bp- 120/80

PR- 88bpm

RR-18cpm

CVS - s1 s2 heard, no murmurs

CNS - NAD

RS - BAE+,NVBS

Dr.Zain(SR)

Dr.Harika(PG1

[22/06, 15:00] Jahnvi 2k18: Op:2023063.4848

19/F

C/o fever since 3 days which is intermittent type not associated with chills and rigor

With body pains and headache since 3 days

No h/o retro-orbital pain , cold , cough , vomitings , diarrhoea

N/K/C/O: HTN, DM, TB, CAD, Asthma, Epilepsy.

O/E:

Pt is c/c/c

No pallor, edema or exophthalmos

Afebrile

PR:79bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

No raised JVP

CNS: NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Dr. Zain (SR)

Dr. Harika (PG1)

[22/06, 15:50] Rohit Dharma: Op no 20230634239

43/F

C/o B/l shoulder joint,wrist joint,ankle joint since 2 months

Increased more on consumption of meat

Excertional dyspnea present

C/o sob, grade 2 since 1 week

N/H/o chest pain ,orthopnea,palpatations

C/o occasional pedal edema present

N/k/c/o hypertension asthma,epilepsy,CVA,CAP,Bronchial asthma,thyroid disorders

O/e

Patient was c/c/c

Vitals-

Temperature - afebrile

Bp- 130/80

PR- 82bpm

RR-16cpm

CVS - s1 s2 heard, no murmurs

CNS - NAD

RS - BAE+,NVBS

Dr.Zain(SR)

Dr.Harika(PG1

[22/06, 15:58] Jahnvi 2k18: Op:20210416232

27/F

C/o generalised swelling of body since 5 days

Facial puffiness since 5 days

C/o giddiness from present

Generalised weakness present

No H/o burning micturition, decreased urine output, urgency

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

O/E :

Pt is c/c/c

PR: 80 bpm

BP: 120/70 mmHg

RR: 18cpm

CVS : S1,S2 +

RS: BAE+,NVBS+

P/A : soft, nontender

CNS : NAD

Dr. Zain(SR)

Dr. Harika(PG1)

[22/06, 17:38] Lohith Sir Gen Med: 35 cases seen. 2 admissions sir

23rd June 2023

[23/06, 09:45] Tejaswi 2k18 Surgery Unit 6: 55/F

Op no.20210500501

Patient came with chief complaints of left shoulder pain since 1 month.

Complaints of bloating of abdomen and indigestion of food since 1 month.

Loss of appetite since 1 month and constipation ( once in 3-4 days)

No c/o fever, pain abdomen, loose stools, vomitings, cough, cold

Not a k/c/o htn, dm, thyroid disorders, epilepsy,asthma, cad, cvd

O/E:

Patient is conscious,coherent, cooperative

Bp:120/80 mm Hg

Pr: 82 bpm

Rr: 18 cpm

Temp: afebrile

No pallor, icterus ,cyanosis, clubbing, lymphadenopathy, pedal edema.

Systemic examination:

Cvs: S1 S2 heard, No murmurs

CNS: nfd

Rs: blae+, NVBS

P/a: soft, non tender

Sr: Dr Nikhitha

Jr: Dr. Vivek( Pg Y1)

[23/06, 09:46] Tejaswi 2k18 Surgery Unit 6: 55/F

Op no.20210500501

Patient came with chief complaints burning and tingling sensation since 2 years.

Complaints of burning micturition since 2 years.

K/c/o

htn since 8 years.( On tab telma 40 mg PO/od)

Dm since 8 years ( on tab metformin 500 mg + glimiperide 2 mg 1/2 tab po/bd)

left shoulder pain since 1 month.

H/o ? Potts spine 8 years ago(used ATT for 6 months)

Not a k/c/o , thyroid disorders, epilepsy,asthma, cad, cvd

O/E:

Patient is conscious,coherent, cooperative

Bp:120/80 mm Hg

Pr: 96 bpm

Rr: 20 cpm

Temp: afebrile

No pallor, icterus ,cyanosis, clubbing, lymphadenopathy, pedal edema.

Systemic examination:

Cvs: S1 S2 heard, No murmurs

CNS: nfd

Rs: blae+, NVBS

P/a: soft, non tender

Sr: Dr Nikhitha

Jr: Dr. Vivek( Pg Y1)

[23/06, 10:08] Harika 2k18 Junior: Op no. 20210511102

A 42 year old male patient who is a k/c/o Acute on chronic liver disease with low grade esophageal varices,cholecystitis,pancytopenia secondary to B 12 deficiency,Alcohol and tobacco dependency came for follow up.

C/o Rt.Hypochondriac pain since 6 months.

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

On Examination:

Pt is c/c/c

Bp-120/80 mmHg

Pr-86bpm

Rr-19 cpm

Temperature -afebrile

Pallor+

Icterus+

No cyanosis,, clubbing, lymphadenopathy, generalised edema.

Oral petechiae+

Systemic examination:

P/A- Pt complains of RT.hypochondriac pain .

Cvs- S1,S2 heard no murmurs

Rs-BAE+ NVBS Heard

Cns- Nfd

Dr.Nikitha (SR)

DR.Vivek(pgy1)

[23/06, 10:17] Harika 2k18 Junior: Op No-20210518535

A 42 year old female patient presented to OPD with C/o Headache in parietal region which is throbbing type everyday during night before sleep which lasts for 4 hours in the night , associated with tingling like

sensation.

Headache is associated with photophobia.

Headache is not associated with phonophobia,giddiness,nausea.

C/o inability to sleep due to headache since 1 month.

Pt is not a k/c/o DM,Htn,CVA,Cad,Tb,asthma, epilepsy.

On examination:

Pt is Afebrile

Bp-120/70 mmHg

Pr-71bpm

Rr-20 cpm

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, generalised edema.

Systemic examination:

Cvs- S1,S2 heard no murmurs

Rs-BAE+ NVBS Heard

Cns- Nfd

P/A-Soft and nontender.

Dr.Nikitha (SR)

Dr:Pavan(Pgy2)

[23/06, 10:23] Tejaswi 2k18 Surgery Unit 6: 70/F

Op no.20230635419

Patient came with chief complaints of giddiness since 2 months with no postural variation, falls, nystagmus, tinnitus.

No complaints of headache, difficulty in micturition, sob, chest pain, pedal edema.

K/c/o Htn since 6 years ( on tab. Metoprolol- 50 mg + tab amlodipine 5 mg PO/od)

K/c/o cad 10 years ago ( on tab dytor plus 50/10mg, tab nitroglycerin 2-6 mg , tab trimetazidine 35 mg)

Not k/c/o dm, thyroid disorders, asthma, epilepsy.

O/E:

Patient is conscious,coherent, cooperative

Bp: 140/70mm Hg

Pr:90 BPM

Rr:20 cpm

Temp: afebrile

Systemic examination:

Cvs: S1, S2 heard

No murmurs

Raised Jvp

CNS: nfd

Rs: blae+, NVBS

P/a: soft , nontender

Sr: Dr Nikhitha

Jr: Dr Vivek( Pgy1)

[23/06, 10:32] Harika 2k18 Junior: Op no.20230635420

A 58year old female patient came to OPD with c/o Generalised body pains since 2 years

C/o indigestion of food since 2 years

C/o tingling sensation of B/L hips since 1 year.

No c/o fever,pain abdomen,cough,cold, vomiting,loose stools, burning micturition.

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

On examination:

Pt is c/c/c

Temperature -Afebrile

Bp- 100/70 mmHg

Pr-68 bpm

Rr- 18 cpm

Pallor present

No icterus, cyanosis, clubbing,generalised lymphadenopathy,edema.

Dr.Nikitha (SR)

DR.Vivek(pgy1)

[23/06, 11:02] Sreelekha ❤: Op no: 20210513405

A 15 year old male came with the complains of cough since 2 days not associated with sputum, no postural, diurnal variation or seasonal variation.

He also complains of cold since 2 days.

Not associated with fever, headache.

History of similar complains in the past (6 months back). Resolved on taking medication. (Unknown syrup).

N/K/C/O DM, HTN, asthma, thyroid disorders, epilepsy.

On examination:

Patient is concious, coherent and cooperative.

Temperature: Afebrile

PR: 82 bpm

BP: 110/70 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[23/06, 12:20] Sreelekha ❤: The patient was adviced adequate hydration and symptomatic treatment.

[23/06, 12:39] Harika 2k18 Junior: Counselling about getting admitted in Deaddiction centre for substance abuse , and reassurance about ,it takes time for the liver enzymes to come down.

[23/06, 12:42] Harika 2k18 Junior: Pt adviced to avoid triggers which aggravate or precipitate the headache.

Symptomatic treatment.

[23/06, 12:43] Sreelekha ❤: Op no. : 20230636041

A 75 year old male came with the complains of cough since 5 days associated with sore throat

The cough is associated with sputum which is

scanty, whitish in colour and mucoid in consistency. No blood tinge seen.

Cough increased during night time.

No history of fever, difficulty in swallowing.

K/c/o HTN since 3 years on regular medication (amlong -AT 50/25 PO/OD)

N/K/C/O DM, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is concious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 78 bpm

BP: 120/70 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs, no increase in JVP

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[23/06, 12:45] +91 81797 90837: Op no: 20230636000

A 41 year old male came with the complains of swelling of lower limbs since 20 days associated with pain in calf since 1 month

H/o Herbal medirine intake since 5 days,

K/C/O: Jaudice: (10 days using medication for the same)

K/C/C: Hypokalemia since 1 month

( symptoms decreased on syrup Potklor alternate days)

Alcoholic last binge 3 days back

Non Smoker

N/K/C/O DM, HTN, asthma, thyroid disorders, epilepsy.

Vitals

Temperature: Afebrile

PR: 92 bpm

BP: 100/50 mmHg

On examination:

Patient is concious, coherent and cooperative.

Systemic examination:

Jvp not raised

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Lower limb : range of movement-normal

Peripheral pulses present

B/L grade 2 pitting edema present

SLRT -ve

[23/06, 12:53] +91 81797 90837: Op no: 20230636039

A 25 year old female came with the complains of increase frequency of Micturation since 1 week with nocturia (15-20 times in morning 4-5 times in the night)

C/O: Burning Micturation since 1 week

N/H/O: fever , abdominal pain , loose stools, vomitings

No similar complains in past

N/K/C/O DM, HTN, asthma, thyroid disorders, epilepsy.

On examination:

Patient is conscious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 74bpm

BP: 110/70 mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[23/06, 13:00] Dr. Rakesh biswas: What were her triggers?

[23/06, 13:01] Dr. Rakesh biswas: ?? What was done for the patient?

[23/06, 13:17] Sreelekha ❤: Op no: 20230636516

A 65 year old male came with the complains of fever and cough since 15 days

Fever associated with chills(evening rise of temperature)

Cough associated with sputum which was of scanty amount whitish, mucoid, non blood tinged. No diurinal or positional variation

H/o generalised weakness since 15 days

H/o decreased appetite since 10 days

N/H/O significant weight loss

H/o CAD - 8years on medication ( Nitroglycerin,Nicorndil,clopidogril & aspirin)

S/p : PTCA 8years

K/C/O HTN since 8 years on regular medication( unknown)

N/K/C/O DM, asthma, thyroid disorders, epilepsy, TB.

On examination:

Patient is concious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 76bpm

BP: 110/70 mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[23/06, 13:19] Sreelekha ❤: The patient was adviced Adequate hydration and symptomatic treatment

[23/06, 13:30] +91 81797 90837: Op no: 20230636009

A 55 year old female came with the complains of pain in the Rt hypocondrium since 2 days

Pricking type pain,

Non radiating ,

No postional variation

N/H/o fever and vomiting

H/o similar complaints 4 months ago

H/o constipation since 4 months

H/o Acute Pancreatitis 4 months back

N/K/C/O HTN ,DM ,TB, ASTHMA

On examination:

Patient is concious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 74bpm

BP: 100/70 mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

[23/06, 14:41] Sowmya Bharadwaj: Op no: 20230636542

A 40 year old male came with

C/o pain in right shoulder since 3 days, non-radiating type

No aggravating and relieving factors.

C/o numbness of right hand since three days

C/o parasthesias in right hand since 3 days

C/o loin pain since 3 days

No h/o trauma

Past history -

Similar complaints in the left lower limb 1 week ago

K/c/o DM since 5 YEARS on regular medication (Tab Metformin 500mg )

K/c/o Hypertension since 2 months ( not on medication)

N/K/C/O Asthma, epilepsy, Thyroid disorders, TB, CVA, CAD.

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy , edema

Vitals-

Temperature: Afebrile

PR: 80bpm

BP: 100/60 mmHg

Systemic examination:

CNS-

Reflexes Right. Left

B +2. +1

T. +2. +1

S. +2. +1

K. +2. +1

A. +2. +1

Plantar. Flexor. Flexor

Power -

RIGHT UL 3/5

LEFT U/L 5/5

RIGHT LL 5/5

LEFT LL - 5/5

TONE -

RIGHT UL- N

LEFT U/L -N

RIGHT LL - N

LEFT LL - N

CVS: S1 S2+, no murmurs

RS: BAE+ NVBS+

P/A: soft , non-tender

The patient was advised Nerve conduction studies at outside hospital and came for the same.

[23/06, 15:49] Sowmya Bharadwaj: Op no: 20210327237

A 67 year old male came with

K/c/o hypertension since 20 years on regular medication (Tab Amlodipine 10 mg )

K/c/o type II Diabetes mellitus since 20 years on Inj. MIXTARD 25 UNITS IN THE MORNING AND 20 UNITS IN THE NIGHT.

N/K/C/O Thyroid disorders, epilepsy, TB, CVA, CAD.

General examination -

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 88 bpm

BP: 120/60 mmHg

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

The patient came for follow up and was advised for admission, but he was not willing.

Advice given to the patient -

1. Strict Diabetic diet

2. Moderate physical activity

3. Salt restriction.

[23/06, 15:50] Sowji: Op no: 20230636085

A 58 year old female came with

-c/o headache in the temporal region since 20 days associated with neck pain , increased with sneezing.

-C/o cold with runny nose since 2-3 months

-C/o Giddiness since yesterday

Nystagmus test : Negative

Rhombergs test: Negative

PAST HISTORY:

K/C/O HTN since 1 year, not on regular medication

N/K/C/O DM, Hypertension, Thyroid disorders, epilepsy, TB, CVA, CAD.

GENERAL EXAMINATION -

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, edema, lymphadenopathy.

VITALS-

Temperature: Afebrile

PR: 74 bpm

BP: Supine: 120/60 mmHg

Standing: 130/70

No orthostatic hypotension

SYSTEMIC EXAMINATION:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Patient was advised for admission but was not willing.

Plan of care: Adequate hydration and Symptomatic treatment

[23/06, 15:50] Sowji: Op no: 20230636570

A 20 year old male came with

-c/o high grade fever since 5 days

It was intermittent, relieved with medication

It was associated with chills and rigors , dry cough and vomitings (7-8 episodes/ day)

-C/o abdominal pain in the right hypochondrium , which was of burning type since 5 days.

-C/o generalized weakness and headache since 5 days

-C/o burning micturition since 5 days

H/o non veg consumption 6 days ago

PAST HISTORY:

H/o B/L Renal calculi - surgery done 2 months ago

N/K/C/O DM, Hypertension, Thyroid disorders, epilepsy, TB, CVA, CAD.

GENERAL EXAMINATION -

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, pedal edema lymphadenopathy.

VITALS-

Temperature: Afebrile

PR: 74 bpm

BP: 110/70 mmHg

SYSTEMIC EXAMINATION:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Patient was advised for admission but was not willing.

Plan of care: Advice temperature monitoring 4th hourly at home, so that we can plot a Fever chart.

[23/06, 15:51] Sowji: Op no: 20230636594

A 23 year old female came with

-c/o headache since 1 year ( hemicranial, throbbing type) not associated with vomiting, nausea, photophobia, phonophobia.

C/o Giddiness since 6 months.

No c/o Fever, pain abdomen, loose stools, cold , cough.

PAST HISTORY:

K/c/o Hypothyroidism during pregnancy ( no follow up after delivery)

N/K/C/O DM, Hypertension, epilepsy, TB, CVA, CAD.

GENERAL EXAMINATION -

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, pedal edema lymphadenopathy.

VITALS-

Temperature: Afebrile

PR: 74 bpm

BP: 100/60 mmHg

SYSTEMIC EXAMINATION:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Patient was advised for admission but was not willing.

Plan of care: Adequate rest and Symptomatic treatment

[23/06, 16:11] Sowmya Bharadwaj: Op no: 20230636638

A 31 year old female came with c/o headache since three days radiating to neck

C/o tingling sensation of both upper limbs and lower limbs since 3 days

H/o lifting of heavy weights present

No h/o Nausea, vomiting, fever, cold and cough

No h/o blurring of vision

No h/o trauma

N/K/C/O Hypertension, DM, Thyroid disorders, epilepsy, TB, CVA, CAD.

General examination -

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 74 bpm

BP: 120/70 mmHg

On L/E

C SPINE

ROM - NORMAL

PARASPINAL MUSCLE STIFFNESS PRESENT

C spine disc spaces- Normal

C4-C5 Spinal tenderness+

L- spine -

ROM - NORMAL

PARASPINAL MUSCLE STIFFNESS - Absent

SLRT - Negative

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

The patient was advised for admission, but was was not willing.

Advice given to the patient -

1. Physiotherapy

2. C- spine collar

3. Avoid lifting heavy weights

4. Adequate rest

24th June 2023

[24/06, 09:39] Neerja: Op no: 20230636951

A 27 year old male came with complaints of Pain abdomen in hypogastric region and left Iliac region since 1 week

Aggravated on taking spicy food

C/o burning micturition since 1 week

Relieved by using medication

C/o lower backache since 1 week non radiating type.

No c/o fever

N/K/C/O HTN, DM,asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

No pallor,cyanosis,clubbing,icterus,lymphadenopathy

Temperature: Afebrile

PR: 80bpm

BP: 120/80 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft

Tenderness present in hypogastric region

Dr.Sushmitha(SR)

Dr.Nithin(PGY1)

Advice:

Pt Was advised to avoid spicy foods and symptomatic treatment.

[24/06, 09:42] Aruna Nephro Icu Junior: Op no: 20210523524

A 42 year old male came with complaints of Decreased Urine Output since 3 days.

No H/O Fever

No H/O SOB,Pedal Edema Chest Pain, Palpitations.

N/K/C/O HTN, DM,asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

No Pallor,cyanosis,clubbing,icterus,lymphadenopathy

Temperature: Afebrile

PR: 98bpm

BP: 110/80 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: Soft and non tender

Dr.Sushmita(SR)

Dr.Nithin(PGY1)

Advice:

Pt advised to get admitted but was not willing .

[24/06, 10:27] Aruna Nephro Icu Junior: Op no: 20230637269

A 34year old female came with complaints of diffuse Pain Abdomen since 10 days .Pain is squeezing in type for first 10 min and Dull Boring type throughout the day.

C/O Burning Micturition since 2 days

No H/O Nausea , Vomitings, Loose stools, Fever

K/C/O Hypothyroidism since 20 years (Taking Tab.Thyronorm 75mcg )

Cold Intolerance present

Anxiety present

N/K/C/O HTN, DM,asthma, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

No Pallor,cyanosis,clubbing,icterus,lymphadenopathy , Edema

Temperature: Afebrile

PR: 68bpm

BP: 110/70 mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: Soft and non tender, Supra Pubic region hard on palpation .

Local Examination-(Thyroid)-Goitre present.

Dr.Sushmita(SR)

Dr.Nithin(PGY1)

Advice:

Plenty of Oral Fluids intake and lifestyle Modification.

[24/06, 10:48] Neerja: Op no: 20230637290

A 53 year old female came for follow up for Diabetes Mellitus since 5 years

No polyuria,polyphagia,Polydypsia,Nocturia

C/o Burning sensation ,Numbness of feet since 5 years decreased on taking medication stopped 1 year ago.

On Tab Metformin 500mg Po /OD

No H/o Blurring of vision,decreased urine output

Her dietary history includes

Rice 2 times/day with 1 cup of curry+1cup dal Morning and afternoon

At night 2 chapathis+1 cup dal

N/K/C/O HTN, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is conscious, coherent and cooperative.

No pallor,cyanosis,clubbing,icterus,lymphadenopathy

Temperature: Afebrile

PR: 80bpm

BP: 130/90 mmHg

CVS: S1 S2+, no murmurs

RS: BAE+ NVBS+

P/A: soft ,non tender

CNS:

Sensory:Rt and left

Pain u/ l and L/l Normal

Touch U/L and L/l Normal ,Right L/l reduced

Propioception U/l 10/10, L/l 10/10

Vibration Right U/l L/l decreased ,Left U/l,L/l Normal

Diabetes with peripheral neuropathy

Dr.Sushmitha (SR)

Dr.Deepika(PGY2)

Advice:

Pt Was advised to follow Strict Diabetic diet and moderate physical activity.

[24/06, 11:21] Aruna Nephro Icu Junior: Op no: 20230637836

A 45yr old male came with C/O left sided Chest pain since 1 day, non radiating associated with severe sweating.

H/O SOB Grade 3 present.

No H/O Palpitations ,Giddiness

No H/O Fever , Headache ,Nausea ,Vomitings

N/K/C/O HTN, DM,asthma, epilepsy,Thyroid Disorders, TB, CVA, CAD

Chronic Alcoholic -stopped consuming 1 year back .

No H/O Smoking

On examination:

Patient is conscious, coherent and cooperative.

General Examination:

No signs of Pallor,cyanosis,clubbing,icterus,lymphadenopathy , Edema

Vitals:

Temperature: Afebrile

PR: 78bpm

BP: 100/60 mmHg

Systemic Examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: Soft and non tender

Dr.Sushmita(SR)

Dr.Nithin(PGY1)

[24/06, 11:55] Neerja: Op no: 20230637838

A 20 year old female came with the complains of fever and cold since 4 days

Fever high grade intermittent not associated with chills relieved by taking medication.

C/o Cough not associated with sputum since 1 day

H/o generalised weakness since 1 day

N/K/C/O DM,Hypertension ,asthma, thyroid disorders, epilepsy, TB.

On examination:

Patient is concious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 76bpm

BP: 110/80 mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

1.Pt Was advised symptomatic treatment

2.Adequate rest and hydration

[24/06, 12:03] Neerja: Op no: 20230637786

A 65 year old female came with complaints of Shortness of Breath since 15 days

Gradually progressed to MMRC Grade 3

Relieved since 10 days to Grade 2

Patient is on inhaler ( unknown) stopped 10 days back

H/ o Wheeze present.

N/K/C/O Diabetes,TB,thyroid disorders, epilepsy, CVA

Hypertensive since 2 months not under medication

On examination:

Patient is conscious, coherent and cooperative.

No pallor,cyanosis,clubbing,icterus,lymphadenopathy

Temperature: Afebrile

PR: 70bpm

BP: 150/90 mmHg

CVS: S1 S2+, no murmurs,apex at 6th ics,jvp not raised

RS: BAE+ NVBS+,No wheeze

P/A: soft ,non tender

CNS: HMF intact,NAD

Dr.Sushmitha (SR)

Dr.Deepika(PGY2)

Advice:

1.Salt Restriction

2.Avoid allergens

3.6 minute walk test.

[24/06, 12:37] Aruna Nephro Icu Junior: Op no: 20230637803

A 63yr old male came with C/O tingling sensations of both upperlimbs on lying to one side .

No H/O Neck pain,Shoulder pain.

No C/O Headache , Fever

No H/O Fever , Headache ,Nausea ,Vomitings

K/C/O Type 2 DM since 15 years on H.Mixtard Insulin(300---×----300)

N/K/C/O HTN,Asthma, epilepsy, TB, CVA, CAD.

No H/O Smoking or Alcohol intake

On examination:

Patient is conscious, coherent and cooperative.

General Examination:

No signs of Pallor,cyanosis,clubbing,icterus,lymphadenopathy , Edema

Vitals:

Temperature: Afebrile

PR: 84bpm

BP: 130/70 mmHg

Systemic Examination:

CVS: S1 S2+, no murmurs

CNS:

Sensory:Rt and left

Pain u/ l and L/l Normal

Touch U/L and L/l Normal ,Right L/l normal

Propioception U/l 10/10, L/l 10/10

Vibration Right U/l L/l decreased ,Left U/l,L/l Normal

RS: BAE+ NVBS+

P/A: Soft and non tender

Dr.Sushmita(SR)

Dr.Nithin(PGY1)

Advice- Pt advised to follow diabetic diet and moderate activity.

[24/06, 12:45] Neerja: Op no: 20230637954

A 28 year old male came with complaints with pain abdomen and distension since yesterday

Pt had outside food consumption yesterday.

Pt c/o 1 episode of vomiting 2 hours post food intake non projectile, non bilious, non blood tinged

C/o loose stools 3 episodes

Non bulky watery,non foul-smelling immediately after food intake

NO c/ fever

K/c/o Diabetes since 2 years on Tab Glimi M1 po/od

Polyuria present

No polyphagia, Polydypsia, tingling,Numbness, burning feet,Blurring of vision

N/K/C/O Hypertension, DM,thyroid disorders, epilepsy, CVA

His diet history includes

Morning 1 cup rice+ dal

Afternoon 1cup rice +curry or dal

Night 1cup rice +dal

On examination:

Patient is conscious, coherent and cooperative.

No pallor,cyanosis,clubbing,icterus,lymphadenopathy

Temperature: Afebrile

PR: 80bpm

BP: 120/80 mmHg

P/A: soft ,non tender,Bowel sounds heard

CVS: S1 S2+, no murmurs

RS: BAE+ NVBS+,

CNS: No focal neurological deficit

Dr.Sushmitha (SR)

Dr.Deepika(PGY2)

Advice:

1.Strict diabetic diet

2.Brisk walking daily for 20 minutes

3.symptomatic treatment

[24/06, 14:42] Aruna Nephro Icu Junior: Op no: 20230637813

A 50 year old female came with

C/o pain in B/L knee joints since 8 months and tingling sensations since 2 months

Edema of both Lower Limbs- Pitting type - extending upto Knee , releives on Lying down.

No C/O- palpitations,sweating,giddiness, SOB,

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy , edema

Vitals-

Temperature: Afebrile

PR: 68bpm

BP: 120/70 mmHg

Systemic examination:

CNS-NAD

CVS: S1 S2+, no murmurs

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr.Nithin(PGY1)

Advice

Pt Was advised quadriceps strengthening exercises

Avoid climbing stairs

Symptomatic treatment

[24/06, 14:58] Neerja: Op no: 20230638410

A 50 year old female shepherd by occupation stopped 3 years back came with

C/o B/L knee joints pain since 3 years

Intermittent, dragging type of pain radiating to lower limbs

months and tingling sensations since 2 months under conservative management.

No H/o tingling, Numbness,fever, cough, cold,burning micturition

K/c/o Hypertension since 2 years on unknown medication

N/k/c/o DM,Asthma, CAD,TB ,Epilepsy ,Thyroid disorders

General examination:

L/E

B/l knees crepitus present

Range of movement present

Patellar tap negative

SLRT negative

Sensations normal

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy , edema

Vitals-

Temperature: Afebrile

PR: 84bpm

BP: 130/80 mmHg

Systemic examination:

CNS-NAD

CVS: S1 S2+, no murmurs

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr.Deepika(PGY1)

Advice:

Physiotherapy Exercises

Symptomatic treatment

[24/06, 14:58] Aruna Nephro Icu Junior: Op no: 20230638414

A 25yr old male patient came with complaints of GTCS 1 episode since yesterday lasted for 5 mins and regained consciousness .

Post Ictal confusion present

Tongue bite present

Uprolling of eye balls present.

No C/O Headache

Last episode 1year Back.

No C/O ,Nausea ,Vomitings

K/C/O Epilepsy on medication Since 3yrs( Tab.Phenytoin 100mg OD)

Discontinued medication since 1 year .

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

No H/O Smoking or Alcohol intake

On examination:

Patient is conscious, coherent and cooperative.

General Examination:

No signs of Pallor,cyanosis,clubbing,icterus,lymphadenopathy , Edema

Vitals:

Temperature: Afebrile

PR: 78bpm

BP: 90/60 mmHg

Systemic Examination:

CVS: S1 S2+, no murmurs

CNS : HMF intact , NFND

RS: BAE+ NVBS+

P/A: Soft and non tender

Dr.Sushmita(SR)

Dr.Nithin(PGY1)

Advice-

Pt . was advised to continue medication regularly and avoid triggers and to

Stop Driving .

Safety Precautions during any episode have been explained to the pt attenders.

[24/06, 15:22] Neerja: Op no: 20230637929

A 78year old male came with the complaints of epigastric pain burning type since 15 days

C/o Cough with expectoration since 10 days,mucoid type sputum

H/o generalised weakness and tingling sensation since 1 week

No h/ o Shortness of breath, cold,fever,Nausea,vomitings

K/c/o Hypertension since 40 years on regular medication On Tab clinidipine 10 mg BD,tab Telma 40 mg OD

N/K/C/O DM,asthma, thyroid disorders, epilepsy, TB.

On examination:

Patient is conscious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 84bpm

BP: 120/80 mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

1.Pt Was advised symptomatic treatment

2.salt restriction and avoid spicy foods

[24/06, 15:22] Aruna Nephro Icu Junior: Op no: 20210416810

A 16yr old male patient came with complaints of Frontal Headache since 2months sudden in onset lasting for 3 to4 hrs and resolves by itself.

C/O Cold and cough present

Throat pain present since 1 day

No H/O Fever

No Facial Tenderness

H/O Frontal Sinusitis since 3 to 4 months and on medication.

Facial Heaviness Absent

Facial Tenderness Absent

N/K/C/O HTN,DM,Asthma,EpilepsyTB, CVA, CAD.

No H/O Smoking or Alcohol intake

On examination:

Patient is conscious, coherent and cooperative.

General Examination:

No signs of Pallor,cyanosis,clubbing,icterus,lymphadenopathy , Edema

Vitals:

Temperature: Afebrile

PR: 88bpm

BP: 100/60 mmHg

Systemic Examination:

CVS: S1 S2+, no murmurs

CNS : HMF intact , NFND

RS: BAE+ NVBS+

P/A: Soft and non tender

Dr.Sushmita(SR)

Dr.Nithin(PGY1)

Advice-

Avoid Triggers.

Warm Saline gargles.

Adequate rest and hydration.

[24/06, 17:05] Lohith Sir Gen Med: 20cases seen. 3 admissions from casualty

26th June 2023

[26/06, 09:48] +91 88978 84815: Op no 20230639199

23 yr old male came for regular follow up for hypothyroidism ,he is a k/c since 3 yrs and not using regular medication since 1 1/2 yr

No h/o wt gain or wt loss ,

Normal appetite

No c/o constipation /loose stools

Cold intolerance is present

No k/c/o DM,HTN ,TB , epilepsy,CVA,CAP

On examination:

Patient is conscious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 68bpm

BP: 110/70mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

1.Pt Was advised symptomatic treatment

2.regular follow up with use of medication .

[26/06, 10:16] +91 79930 39089: Op no: 20230639555

Patient c/o headache with neck pain since 1-2 months

Headache is on and off lasting for 2 hours

Relieved by medication

Neck pain is non radiating, relieved by medication

No c/o giddiness, Loc, seizures

K/c/o HTN since 4 years not on regular medication

Not a k/c/o DM 2, TB, epilepsy, CVA, CAD, thyroid disorders, asthma

On examination:

Patient is conscious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 76bpm

BP: 150/90mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Symptomatic treatment

Explained the need for regular medication

[26/06, 10:17] +91 79930 39089: Op no: 20230639527

Pt complaints of left sided chest pain, lt UL pain, LL pain since 6 months, intermittent, relieved on medication

Lt sided chest pain is non radiating, pricking type and associated with vomitings

Lower back ache is Lt sided radiating to Lt lower limb, no tingling sensation.

No H/o weight lifting, trauma

Tailor by occupation

K/c/o hypothyroidism since 3 years and is on tab.thyronorm 25mcg

K/c/o DM 2 since 1 and half year and is on tab.metformin 500mg OD

No k/c/o HTN ,TB , epilepsy,CVA,CAD, asthma

On examination:

Patient is conscious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 90bpm

BP: 130/80mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Evaluate further for chest pain and peripheral neuropathy

Patient is not willing for admission advised symptomatic treatment

[26/06, 10:27] Dr. Rakesh biswas: Was he clinically Hypothyroid or euthyroid?

[26/06, 10:28] Dr. Rakesh biswas: Age gender?

He already appears to be a victim of the overdiagnosis and overtreatment pandemic

[26/06, 10:29] Dr. Rakesh biswas: Write the sequence of events for each patient starting with their routine when they were absolutely alright

Don't waste valuable opd time by writing useless negative histories

[26/06, 10:32] +91 88978 84815: Euthyroid sir

[26/06, 10:35] +91 88978 84815: Op no: 20210411826

Pt is 20 yr old with c/o fever on and off ,high grade , intermittent associated with chills and rigor since 1 week

C/o dry cough since 1 week

N/K/C/O DM, htn ,asthma, thyroid disorders, epilepsy, TB.

On examination:

Patient is conscious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 96 bpm

BP:90/60 mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Pt is advised for symptomatic treatment

[26/06, 11:30] +91 79930 39089: Op no: 20230640069

41 M came with c/o pain in the whole back region since 3-4 years

Pain present after doing work for almost 4 hours daily

He works as a barber in a temple for 2 days in a week and for the rest of the week he does farming work in fields(cotton fields)

Pain aggravates on after ploughing the field and also after driving for 4 hours and also on bending forward

C/o difficulty in breathing after ploughing the field for an hour

H/o constipation present, fresh blood in stools, on and off after eating non veg food, it happens 1-3 times a year

O/E

Tenderness present over the lumbar spine and thorasic spine region

Vitals

Temperature: Afebrile

PR: 79bpm

BP: 120/90mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice

Symptomatic treatment

Back rest

Advised not lifting heavy weights

Physiotherapy for back

Patient advised for admission but not willing

Patient agreed to get admitted after 7 days if pain doesn't subside

[26/06, 12:03] +91 79930 39089: Op no: 20230640184

56 M came with c/o left sided chest pain, burning type, localised, non radiating since 6-7 months

It is intermittent and aggravates on eating spicy food and resolves on its own.

No c/o palpitations, difficulty breathing

K/c/o DM 2 since 15 years and is in Glimipiride 2 mg and metformin 500 mg po/bd

K/c/o HTN since 15 years and is on enalapril 10mg po/od

Patient works as a distributor and currently he is not doing any work

He says he is not working because of sun and is scared of sun stroke.

Vitals

Temperature: Afebrile

PR: 100bpm

BP: 160/100mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Strict diabetic diet

Exercise

Avoid spicy food

[26/06, 12:36] +91 88978 84815: op no 20230640226

A 73 yr old male came to opd with

c/o pain abdomen is insidious , progressive , aggravated with spicy food since 6 month

C/o indigestion since 6 month

C/o difficulty in swallowing since 3 month

C/o burning micturition since 6 month

He works as carpenter and his work life isn't disturbed

N/K/C/O DM,asthma, thyroid disorders, epilepsy, TB.

On examination:

Patient is conscious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 90 bpm

BP:130/90 mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Pt is advised for symptomatic treatment

Avoid spicy food and regular diet schedule.

[26/06, 12:45] +91 79930 39089: Op no: 20230640211

45 M came with c/o pitting type of pedal edema since morning of Lt lower limb

C/o pain over Lt lower limb since 3 days

Pain is continuous aggravated on walk-in and relives on taking rest

He works as a shopkeeper in clothing shop

He is unable to walk during work yesterday for long time

Local examination

No local rise of temperature, tenderness present over calf region

Ankle brachial index- 0.76- moderate arterial disease

Vitals

Temperature: Afebrile

PR: 72bpm

BP: 120/70mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Further evaluation for arterial disease

Rest

[26/06, 12:53] +91 88978 84815: Op no : 20230639576

C/o fever since 1 day high grade intermittent associated with chills and rigor c/o dry cough , throat irritation and pain

C/o headache

N/K/C/O DM,asthma, thyroid disorders, epilepsy, TB.

On examination:

Patient is conscious, coherent and cooperative.

Vitals

Temperature: Afebrile

PR: 84bpm

BP: 120/80 mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

1.Pt Was advised symptomatic treatment

[26/06, 14:06] +91 79930 39089: Op no:20230640655

39 F came with c/o pain in the neck region associated with headache in temporal region since 1 month

Pain is non radiating type

With frequency once in

2 -3 days lasting for 1 hour and relieved on taking medication

Patient does household work and since 1 month she is able to do the work but slower than before

H/o cardiac surgery 18 years back for ?septal defect

O/E

No tenderness over spine

ROM- normal

Vitals

Temperature: Afebrile

PR: 92bpm

BP: 120/80mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice

Symptomatic treatment

[26/06, 14:20] +91 79930 39089: Op no: 20230640177

57 F came with c/o abdominal discomfort and pain since 1 years

Increased in intensity since 5 days

Burning sensation present, nausea+

Abdominal bloating+, belching+

Aggravated on taking spicy food

Patient does farming work and she is able to do it now also

Vitals

Temperature: Afebrile

PR: 84bpm

BP: 120/80mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Symptomatic treatment

Avoid spicy food

[26/06, 14:30] +91 88978 84815: Op no 20230640180

65 F came with c/o generalised body pain since 1 yr

C/o epigastric squeezing type of pain, after taking food, since 1 yr on and off

C/o constipation since 5 days

C/o oral ulcers since 5 days

Patient does farming work and she is able to do it now also

Vitals

Temperature: Afebrile

PR: 84bpm

BP: 120/80mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Symptomatic treatment,

Avoid strenuous work

Avoid spicy food

[26/06, 14:47] +91 79930 39089: Op no: 20210309857

27M came with c/o generalized body weakness since 15 days

C/o body pains since 15 days

C/o fever since 15 days intermittent type,low grade relieved on medication not associated with chills and rigors

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

Patient works as a shopkeeper and since 15 days he is unable to work with same intensity as before.

Vitals

Temperature: Afebrile

PR: 80bpm

BP: 150/100mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Symptomatic treatment

Adequate rest and hydration

[26/06, 14:52] +91 88978 84815: Op no 20230640281

40 female Pt c/o pain abdomen since 1 day

Loose stools since 1 day , 4 to 5 ep ,mucoid ,non blood stained .

No h/o. outside food intake

No c/o nausea, vomiting , burning micturition

Patient does farming work and she is able to do it now also

Vitals

Temperature: Afebrile

PR: 62bpm

BP: 130/90mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , tenderness in right lumbar and epigastric region .

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Symptomatic treatment

Diet regulations explained.

[26/06, 14:58] +91 79930 39089: Op no:20230640713

Pt came with c/o neck pain and unilateral headache since 1 year

The pain and headache is intermittent in nature which occurs once a month and lasts for 2-3 hours and since 10 days

the intensity has increased

It relieves on taking medication (NSAIDS)

H/o trauma to right shoulder is present 10 years back

C/o decreased near vision

Patient does farming and she is able to do it even now

Vitals

Temperature: Afebrile

PR: 79bpm

BP: 130/90mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Pt advised for symptomatic treatment

Adequate rest

[26/06, 14:59] +91 88978 84815: OP: 20210217786

A 42F a k/c/o DM since 2 months on medication came to the OPD for follow up

Inv done on 26/6/23

FBS: 121 mg/dl

PLBS: 151 mg/dl

O/E:

Pt is c/c/c

Afebrile

PR:72bpm

BP: 130/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Dr.Sushmitha (SR)

Dr.Nithin( Pgy1)

Strict diabetic diet

T METFORMIN 500MG PO OD before food

[26/06, 15:05] +91 79930 39089: Op no: 20210309989

A 36 yearold female k/c/o anaemia with blood loss due to ? Right ovarian cyst

C/o sob since 2 months Grade-3 no aggravating and relieving factors

Not associated with palpitations ,chest pain, orthopnea ,PND

No h/o pedal edema

C/o vomitings since two months, intermittent after taking food non-bilious non-projectile around 1 to 2 episodes per week

C/o throat pain with dysphagia since two months

C/o cough since four months not associated with sputum

No H/O fever

H/o belching with regurgitation

Since two years and on medication, tab.Rantac for 1and half year and stopped 6 months back

K/c/o GERD with anaemia

On examination:

Patient is conscious, coherent and cooperative.

Pallor: +

No cyanosis,clubbing,icterus

Temperature: Afebrile

PR: 78bpm

BP: 110/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS

P/A: soft , non tender

Dr.Sushmitha(SR)

Dr.Nithin(PGY1)

Advice

Avoid spicy food

Diet-iron rich food

Patient is advised to admit but not willing for admission

[26/06, 15:11] +91 79930 39089: Op no:20230640867

38F

C/o fever since 3 days

Low grade not associated with chills and rigors, releived on taking medication

Generalized body pains present

Headache , nausea +

Loose stools , vomiting, cold , cough absent

Burning micturation absent

C/o epigastric pain since 3 days

Indigestion present

Throat pain present

K/c/o HTN since 6 years on tab. Telma 40mg po/od

On examination

Pallor present

No icterus cyanosis clubbing lympadenopathy edema

Oral congestion present

CVS S1 s2 heard no murmurs

RS BAE NVBS+

Vitals

BP: 110/80mmhg

PR: 78 bpm

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice

Advised symptomatic treatment

Adequate rest

Pt advised for admission but not willing

[26/06, 15:17] +91 88978 84815: Op no 20230639579

70 male Pt came to opd with c/o cough with sputum since 1 month

H/o TB in past 5 yrs ago ,att used for 6 months .

H/o smoking since 10 yrs

He is farmer by occupation and does he daily worker .

O/E:

Pt is c/c/c

Afebrile

RR: 30 cpm

PR:58bpm

BP: 110/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,non tender

Refer to pulmonologist.

Symptomatic treatment

[26/06, 15:31] +91 79930 39089: Op no: 20230640258

35F came with c/o neck pain and headache since 1 month

Dizziness since 2 days

Neck pain and headache aggravated on doing household work

Patient works as a laborer and is unable to work as before

O/e

No tenderness over spine

ROM -normal

Vitals

Temperature: Afebrile

PR: 76bpm

BP: 120/80mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Symptomatic treatment

Adequate rest

[26/06, 15:47] +91 79930 39089: Op no: 20230640991

19M

C/o fever since 2 days

Insidious onset, intermittent , not associated with chills and rigors , releived on taking medication

Dry cough +

Cold +

Headache +

Bodypains +

Nausea , vomitings , loose stools absent

Patient is a student

Vitals

Temperature: Afebrile

PR: 76bpm

BP: 130/90mmHg

Systemic examination

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

Dr.Sushmitha (SR)

Dr .Nithin(PGY1)

Advice:

Symptomatic treatment

Steam inhalation

Plenty of oral fluids

[26/06, 15:48] +91 88978 84815: Op no 20230640781

Pt is 23 yr male

C/o chest pain radiating to the left side back of shoulder since 1 1/2 month

C/o left flank pain since 1 month

H/o strenuous work out on and off since 1 yr ,last done since 1 month .

He is a postgraduate and in search of work and can't able to perform daily routine due to pain .

O/E:

Pt is c/c/c

Afebrile

PR:74bpm

BP: 120/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft ,

Left iliac fossa tenderness

Dr.Sushmitha (SR)

Dr.Nithin (Pgy1)

Adv

Neurology opinion

Avoid strenuous work .

[26/06, 16:05] +91 88978 84815: Op no : 20230640182

Pt 50 F c/o excessive sweating since 6 months

H/o Wt loss , cold intolerance , palpitations

K/c/o DM since 2 yrs on medication

Metformin 500 mg + glimipiride 0.5 mg OD

She is a homemaker and is able to do her routine

O/E:

Pt is c/c/c

Afebrile

PR:74bpm

BP: 120/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender .

Dr.Sushmitha(SR)

Dr.Nithin (Pgy1)

Adv

For thyroid function test to rule out hypothyroidism.

Continue medication for diabetes

[26/06, 20:05] Lohith Sir Gen Med: 40 cases seen. 1 admission from casualty sir

27th June 2023

[27/06, 09:25] Srinidhi Kims: Op no:20230641044

A 58 yr old female pt came with complaints of burning sensation over abdomen

And bloating after eating food since 2 days

No Belching

K/c/o thyroid-on thyronorm 50mg

K/c/o HTN since 3yrs- on medication tab.telma 20mg

K/c/o DM II since 4 yrs and on glimileride 1mg and insulin 10 units

N/k/c/o asthma,cvd,TB,epilepsy

Previously she worked as mandal officer but stopped her work 3 yrs back due to severe lower limb pain (lt lower limb varicose veins)

Currently she can do her daily routine

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:110/60 mmhg

PR: 76

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft,non tender

Pt was advised for admission but is not willing to admit

Diagnosis:acid peptic disease

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 09:39] Munya Verma KIMS: Op no 20210109632

Pt is 36 yr male

C/o bloating sensation since 1week and belching present

Aggrevated on spicy and tangy foods

K/c/o DM II since 5 years , tab metformin 500mg - 1and1/2 tablet po/ bd

N/k/c/o HTN, Asthma,CDA

O/E:

Pt is c/c/c

Afebrile

PR:96bpm

BP: 100/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Diagnosis: acid peptic disease

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 09:39] Srinidhi Kims: Op no:20230641062

A 26 yr old male pt came with complaints of

Epigastric pain since 2 days-continuous,dragging type,radiating to left side of the chest

Bloating and belching present

Aggrevated since 2 days

Aggrevated on having spicy food

No c/o sob,chest pain

K/c/o acid peptic disease since 4 yrs

N/k/c/o HTN,DM,thyroid disorders,asthma,cvd,TB,epilepsy

He works as a CA and his work/daily routine is not disturbed

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:120/70 mmhg

PR: 82

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft,non tender

Pt was advised for admission but is not willing to admit

Diagnosis:acid peptic disease

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 09:43] Srinidhi Kims: Op no:20230641045

A 40 yr old male pt came with complaints of

Tingling in both legs since 3 months

Tingling is limited to both legs around ankles till feet ,persistant in nature

No aggravating or relieving factors

No h/o numbness in foot

C/o B/L knee pain since 6 months ,non radiating

No h/o polyphagia,polyuria,blurring of vision

K/c/o DM II since 1 yr and on OHA(didn’t bring medication)

N/k/c/o HTN,thyroid disorders,asthma,cvd,TB,epilepsy

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:110/70 mmhg

PR: 78

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft,non tender

Pt was advised for admission but is not willing to admit

Diagnosis:?peripheral neuropathy

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

GRBS monitoring at home

Symptomatic treatment

[27/06, 10:00] Munya Verma KIMS: Op no 20230641058

Pt is 40 yr female

C/o chest pain since : 1 month relieved on taking food , c/o burning sensation in epigastric region , non radiating pain .

C/o sob on walking ( 500m ) , relived on rest .

No pitting edema, palpitations present

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

O/E:

Pt is c/c/c

Afebrile

PR:86 bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Diagnosis: peptic ulcer

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 10:13] Munya Verma KIMS: Op no : 20230641483

Pt is 60 yr female

C/o right side chest pain since 2 days , no radiation of pain

C/o sob due to chest pain

K/c/o acid peptic disease since 7-8 years and on regular medication tab.PAN 40 mg ( epigastric pain , belching present)

K/c/o HTN since 15years , on tab telmisartan 20 mg po/bd

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

O/E:

Pt is c/c/c

Afebrile

PR:76 bpm

BP: 120/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Diagnosis: Acid peptic disease Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 10:43] Srinidhi Kims: Op no:20230641843

A 20 yr old female pt came with complaints of

Pain in lower abdomen since last night,insidious in onset ,gradually progressive and Aggrevated on doing strenuous abdominal exercise in the morning

C/o bloating of abdomen since 2 days

H/o constipation since 2 days

No h/o burning micturition,fever,menstrual irregularities

N/k/c/o HTN,DM,thyroid disorders,asthma,cvd,TB,epilepsy

She is a nursing student

Couldn’t sleep last night due to severe pain

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:110/80 mmhg

PR: 72

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Diagnosis:?muscle cramps

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

High fibre diet

adequate hydration

Symptomatic treatment

[27/06, 10:46] Munya Verma KIMS: Op no 20230641551

Pt is 22 yr female

C/o pain in left lower back since 5 days , increased in intensity since 2 days . intermittent sharp pain, non radiating, increased in supine position.

Not associated with neck and back pain

No previous episodes in past

N/k/c/o HTN, DM , Asthma,CDA , CVD ,TB, thyroid

O/E:

Pt is c/c/c

Afebrile

Pallor present

PR:86 bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , tenderness in left lower back ( lumbar region)

schober test negetive

Pt was advised for admission but is not willing to admit

Diagnosis: lower backache secondary to muscle spasm

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 10:48] Srinidhi Kims: Op no:20230502873

A 32 yr old male pt came with complaints of

Pain in lower abdomen while urinating since 2 days,progressive in nature and Aggrevated since last night

No h/o burning micturition,fever

H/o consumption of alcohol (beer 2-3 bottles) during a function 2 days back

N/k/c/o HTN,DM,thyroid disorders,asthma,cvd,TB,epilepsy

He works as a driver and his work/daily routine is not disturbed

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:120/80 mmhg

PR: 82

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

adequate hydration

[27/06, 11:34] Srinidhi Kims: Op no:20230502873

A 30yr old female pt came with c/o Headache localised to left side since 1 month

She had similar complaint since 7 yrs which aggravated since 1 month

Which is intermittent in nature,aggrevated on lifting weights,tension,and relieved on rest

No Photophobia,Phonophobia

No c/o nausea,giddiness,neckpain

K/c/o hypothyroid since 15 yrs -on medication thyronorm 88mcg

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

She’s a housewife and can do her daily routine without any difficulty

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:120/90mmhg

PR: 76

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 12:51] Srinidhi Kims: Op no:20230642526

A 19yr old male pt came with c/o

Fever, cough(wet)and cold since yesterday body pain since yesterday which are intermittent and progressive

C/o headache in bilateral temporal region since one week which is intermittent

not a known case of DM,HTN,epilepsy,asthma,Thyroid disorders,cad

He’s a pharmacy student

General examination:

Pt is consious,coherent,cooperative

BP:120/90mmhg

PR: 86

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 12:59] Srinidhi Kims: Op no: 20210213763

A 30-year-old male patient presented with complains of pain in epigastric and hypochondrium region since three years which aggravated on taking spicy food and relieved on its own,is pricking type and non-radiating

Generalised weakness and body pain since one week.

Pain in left side of chest(History of trauma -rip fractures ,eight years back)

No history of vomiting,giddiness

History of use of pantoprazole since three years

N/k/c/of hypertension, diabetes,epilepsy, thyroid,asthma

SOB since two months, aggravated on exercise and relieved and rest

no complaints of chest, pain, chest tightness

General examination:

Pt is consious,coherent,cooperative

BP:110/60mmhg

PR: 80

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

Avoid spicy food

[27/06, 13:00] Munya Verma KIMS: Op no 20230642554

Pt is 50 yr male

C/o bilateral pedam edema, pitting type , no aggrevating and reliving factors

C/o SOB since 10 days during climbing stairs , relieved during rest ( grade II -III)

C/O neck pain since 4 days , dizziness present

No H/o headache, nasuea, vomiting

No h/o chest tightness, chest pain , palpitations

H/o HTN 1 year Back and used medication for 10 days only

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

O/E:

Pt is c/c/c

Afebrile

PR:86 bpm

BP: 160/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 15:03] Munya Verma KIMS: Op no 20210513530

Pt is 29 yr male

C/o pedal edema since 4 days , pitting type, grade I

C/o trouble urinating since 4 days

H/o fever 15 days back , diagnosed typhoid, used antibiotics for 1 week

H/o pedal edema since 1 year , intermittent , aggravating on increased work , reliving on rest

No h/o chest pain, palpitation, sob

No h/o burning micturition , decreased urine out

K/c/o DM since 6 months, and in on medication metformin 500mg, glimi 1 mg OD

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

H/o bilateral sholder pain and bilateral knee pain

O/E:

Pt is c/c/c

Afebrile

PR:86 bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 15:06] Srinidhi Kims: Op no: 20210308550

A 42 year-old female patient presented with complains of bloating and belching since 6 days

Indigestion and decreased appetite since 6 days

Pain in left hand since 3 days-dragging type

No h/o nausea,vomitings,neck pain

K/c/o HTN since 6 yrs- is on medication telmisartan and hydrochlorothiqzide

N/k/c/of diabetes,epilepsy, thyroid disorders,asthma

General examination:

Pt is consious,coherent,cooperative

BP:100/60mmhg

PR: 90

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 15:14] Munya Verma KIMS: Op no 20210515041

Pt is 42 yr female

C/o bloating sensation after food since 3 days , belching present

No h/o of chest pain, palpitation,sob

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

O/E:

Pt is c/c/c

Afebrile

PR:86 bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 15:20] Srinidhi Kims: Op no: 20210210990

A 38 year-old male patient presented with complains of

Indigestion since 15 days

Associated with difficulty in swallowing bolus,so has to take along with liquids

Pt had similar complaints since 1 yr ,was intermittent in nature and resolved on dietary changes

No h/o fever,burning micturition,abdominal pain

H/o inadequate sleep since 1 month

He had hard time falling asleep due to personal stress

N/k/c/of HTN,diabetes,epilepsy, thyroid disorders,asthma

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:130/80mmhg

PR: 84

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

Dietary changes-avoid spicy food

Increased intake of leafy vegetables and high fibre diet

[27/06, 17:42] Lohith Sir Gen Med: 30 cases seen. 1 admission sir

28th June 2023

[27/06, 09:25] Srinidhi Kims: Op no:20230641044

A 58 yr old female pt came with complaints of burning sensation over abdomen

And bloating after eating food since 2 days

No Belching

K/c/o thyroid-on thyronorm 50mg

K/c/o HTN since 3yrs- on medication tab.telma 20mg

K/c/o DM II since 4 yrs and on glimileride 1mg and insulin 10 units

N/k/c/o asthma,cvd,TB,epilepsy

Previously she worked as mandal officer but stopped her work 3 yrs back due to severe lower limb pain (lt lower limb varicose veins)

Currently she can do her daily routine

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:110/60 mmhg

PR: 76

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft,non tender

Pt was advised for admission but is not willing to admit

Diagnosis:acid peptic disease

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 09:39] Munya Verma KIMS: Op no 20210109632

Pt is 36 yr male

C/o bloating sensation since 1week and belching present

Aggrevated on spicy and tangy foods

K/c/o DM II since 5 years , tab metformin 500mg - 1and1/2 tablet po/ bd

N/k/c/o HTN, Asthma,CDA

O/E:

Pt is c/c/c

Afebrile

PR:96bpm

BP: 100/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Diagnosis: acid peptic disease

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 09:39] Srinidhi Kims: Op no:20230641062

A 26 yr old male pt came with complaints of

Epigastric pain since 2 days-continuous,dragging type,radiating to left side of the chest

Bloating and belching present

Aggrevated since 2 days

Aggrevated on having spicy food

No c/o sob,chest pain

K/c/o acid peptic disease since 4 yrs

N/k/c/o HTN,DM,thyroid disorders,asthma,cvd,TB,epilepsy

He works as a CA and his work/daily routine is not disturbed

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:120/70 mmhg

PR: 82

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft,non tender

Pt was advised for admission but is not willing to admit

Diagnosis:acid peptic disease

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 09:43] Srinidhi Kims: Op no:20230641045

A 40 yr old male pt came with complaints of

Tingling in both legs since 3 months

Tingling is limited to both legs around ankles till feet ,persistant in nature

No aggravating or relieving factors

No h/o numbness in foot

C/o B/L knee pain since 6 months ,non radiating

No h/o polyphagia,polyuria,blurring of vision

K/c/o DM II since 1 yr and on OHA(didn’t bring medication)

N/k/c/o HTN,thyroid disorders,asthma,cvd,TB,epilepsy

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:110/70 mmhg

PR: 78

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft,non tender

Pt was advised for admission but is not willing to admit

Diagnosis:?peripheral neuropathy

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

GRBS monitoring at home

Symptomatic treatment

[27/06, 10:00] Munya Verma KIMS: Op no 20230641058

Pt is 40 yr female

C/o chest pain since : 1 month relieved on taking food , c/o burning sensation in epigastric region , non radiating pain .

C/o sob on walking ( 500m ) , relived on rest .

No pitting edema, palpitations present

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

O/E:

Pt is c/c/c

Afebrile

PR:86 bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Diagnosis: peptic ulcer

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 10:13] Munya Verma KIMS: Op no : 20230641483

Pt is 60 yr female

C/o right side chest pain since 2 days , no radiation of pain

C/o sob due to chest pain

K/c/o acid peptic disease since 7-8 years and on regular medication tab.PAN 40 mg ( epigastric pain , belching present)

K/c/o HTN since 15years , on tab telmisartan 20 mg po/bd

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

O/E:

Pt is c/c/c

Afebrile

PR:76 bpm

BP: 120/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Diagnosis: Acid peptic disease Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 10:43] Srinidhi Kims: Op no:20230641843

A 20 yr old female pt came with complaints of

Pain in lower abdomen since last night,insidious in onset ,gradually progressive and Aggrevated on doing strenuous abdominal exercise in the morning

C/o bloating of abdomen since 2 days

H/o constipation since 2 days

No h/o burning micturition,fever,menstrual irregularities

N/k/c/o HTN,DM,thyroid disorders,asthma,cvd,TB,epilepsy

She is a nursing student

Couldn’t sleep last night due to severe pain

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:110/80 mmhg

PR: 72

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Diagnosis:?muscle cramps

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

High fibre diet

adequate hydration

Symptomatic treatment

[27/06, 10:46] Munya Verma KIMS: Op no 20230641551

Pt is 22 yr female

C/o pain in left lower back since 5 days , increased in intensity since 2 days . intermittent sharp pain, non radiating, increased in supine position.

Not associated with neck and back pain

No previous episodes in past

N/k/c/o HTN, DM , Asthma,CDA , CVD ,TB, thyroid

O/E:

Pt is c/c/c

Afebrile

Pallor present

PR:86 bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , tenderness in left lower back ( lumbar region)

schober test negetive

Pt was advised for admission but is not willing to admit

Diagnosis: lower backache secondary to muscle spasm

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 10:48] Srinidhi Kims: Op no:20230502873

A 32 yr old male pt came with complaints of

Pain in lower abdomen while urinating since 2 days,progressive in nature and Aggrevated since last night

No h/o burning micturition,fever

H/o consumption of alcohol (beer 2-3 bottles) during a function 2 days back

N/k/c/o HTN,DM,thyroid disorders,asthma,cvd,TB,epilepsy

He works as a driver and his work/daily routine is not disturbed

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:120/80 mmhg

PR: 82

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

adequate hydration

[27/06, 11:34] Srinidhi Kims: Op no:20230502873

A 30yr old female pt came with c/o Headache localised to left side since 1 month

She had similar complaint since 7 yrs which aggravated since 1 month

Which is intermittent in nature,aggrevated on lifting weights,tension,and relieved on rest

No Photophobia,Phonophobia

No c/o nausea,giddiness,neckpain

K/c/o hypothyroid since 15 yrs -on medication thyronorm 88mcg

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

She’s a housewife and can do her daily routine without any difficulty

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:120/90mmhg

PR: 76

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 12:51] Srinidhi Kims: Op no:20230642526

A 19yr old male pt came with c/o

Fever, cough(wet)and cold since yesterday body pain since yesterday which are intermittent and progressive

C/o headache in bilateral temporal region since one week which is intermittent

not a known case of DM,HTN,epilepsy,asthma,Thyroid disorders,cad

He’s a pharmacy student

General examination:

Pt is consious,coherent,cooperative

BP:120/90mmhg

PR: 86

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 12:59] Srinidhi Kims: Op no: 20210213763

Generalised weakness and body pain since one week.

Pain in left side of chest(History of trauma -rip fractures ,eight years back)

No history of vomiting,giddiness

History of use of pantoprazole since three years

N/k/c/of hypertension, diabetes,epilepsy, thyroid,asthma

SOB since two months, aggravated on exercise and relieved and rest

no complaints of chest, pain, chest tightness

General examination:

Pt is consious,coherent,cooperative

BP:110/60mmhg

PR: 80

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

Avoid spicy food

[27/06, 13:00] Munya Verma KIMS: Op no 20230642554

Pt is 50 yr male

C/o bilateral pedam edema, pitting type , no aggrevating and reliving factors

C/o SOB since 10 days during climbing stairs , relieved during rest ( grade II -III)

C/O neck pain since 4 days , dizziness present

No H/o headache, nasuea, vomiting

No h/o chest tightness, chest pain , palpitations

H/o HTN 1 year Back and used medication for 10 days only

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

O/E:

Pt is c/c/c

Afebrile

PR:86 bpm

BP: 160/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 15:03] Munya Verma KIMS: Op no 20210513530

Pt is 29 yr male

C/o pedal edema since 4 days , pitting type, grade I

C/o trouble urinating since 4 days

H/o fever 15 days back , diagnosed typhoid, used antibiotics for 1 week

H/o pedal edema since 1 year , intermittent , aggravating on increased work , reliving on rest

No h/o chest pain, palpitation, sob

No h/o burning micturition , decreased urine out

K/c/o DM since 6 months, and in on medication metformin 500mg, glimi 1 mg OD

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

H/o bilateral sholder pain and bilateral knee pain

O/E:

Pt is c/c/c

Afebrile

PR:86 bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 15:06] Srinidhi Kims: Op no: 20210308550

A 42 year-old female patient presented with complains of bloating and belching since 6 days

Indigestion and decreased appetite since 6 days

Pain in left hand since 3 days-dragging type

No h/o nausea,vomitings,neck pain

K/c/o HTN since 6 yrs- is on medication telmisartan and hydrochlorothiqzide

N/k/c/of diabetes,epilepsy, thyroid disorders,asthma

General examination:

Pt is consious,coherent,cooperative

BP:100/60mmhg

PR: 90

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 15:14] Munya Verma KIMS: Op no 20210515041

Pt is 42 yr female

C/o bloating sensation after food since 3 days , belching present

No h/o of chest pain, palpitation,sob

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

O/E:

Pt is c/c/c

Afebrile

PR:86 bpm

BP: 110/70 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

[27/06, 15:20] Srinidhi Kims: Op no: 20210210990

A 38 year-old male patient presented with complains of

Indigestion since 15 days

Associated with difficulty in swallowing bolus,so has to take along with liquids

Pt had similar complaints since 1 yr ,was intermittent in nature and resolved on dietary changes

No h/o fever,burning micturition,abdominal pain

H/o inadequate sleep since 1 month

He had hard time falling asleep due to personal stress

N/k/c/of HTN,diabetes,epilepsy, thyroid disorders,asthma

General examination:

Pt is consious,coherent,cooperative

Temp:afebrile

BP:130/80mmhg

PR: 84

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Dr.Nikitha (SR)

Dr.Lohith (PGY1)

Advice:

Symptomatic treatment

Dietary changes-avoid spicy food

Increased intake of leafy vegetables and high fibre diet

[27/06, 17:42] Lohith Sir Gen Med: 30 cases seen. 1 admission sir

28th June 2023

[28/06, 10:40] +91 92906 89343: OP no. 20230643236

50 year old female came to opd with c/o headache since 10 days B/L occipital region and frontal

No aura ,photophobia, photophonia

Generalized weakness since 5 days

Generalized myalgias present

Chest discomfort and abdominal tightness present

N/H/O fever, cough, Shortness of breath present

K/C/O HTN on Tab telma 20mg PO/OD

K/C/O T2DM on Tab GLIMT M

examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 94 bpm

BP: 100/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Sushmita (SR)

Dr.Ajay (PG2)

Advice

Symptomatic treatment

[28/06, 11:06] +91 79958 46078: Op no : 20230643276

A 44 years old male who is a auto driver by occupation came with the chief complaints of tingling and numbness of both the UL and LL since 2 days a/w neck pain and not a/w headache ,blurring of vision , fever , nausea and vomiting

K/c/o HTN since 1 year on regular medication(tab.telma 40mg/PO/OD

N/K/c/o DM, Epilepsy, TB,Asthma , CAD

On examination:

Pt is c/c/c

No pallor icterus cyanosis clubbing edema lymphadenopathy

Reflexes Right Left

B 2+ 2+

T 2+ 2+

S 1+ 1+

K 2+ 2+

A 1+ 1+

Plantar Flexor Flexor

Power :

RIGHT UL -3/5

LEFT UL -5/5

RIGHT LL -5/5

LEFT LL - 5/5

TONE

RIGHT UL- N

LEFT UL -N

RIGHT LL - N

LEFT LL - N

CVS S1 s2 heard no murmurs

RS BAE NVBS heard

Vitals

BP: 160/120mmhg(didn’t take medication today )

PR : 98bpm

DR Sushmitha (SR)

DR Deepika (Pgy2)

Advice:

Salt restriction <2g/day

Serial BP recording for 3 days

Regular use of anti hypertensive drugs

[28/06, 11:19] Dr. Rakesh biswas: Copying again here below from this group's description 👇

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

[28/06, 11:53] +91 92906 89343: Op no. 20230643311

27year old female came to opd with the

C/o of headache since 1 week throbbing type of pain associated with occational burning of vision (1-2 min)

H/O fever yesterday

A/W left sided tonic seizure like activity lasting for 1 min with no postnatal confusion

K/C/O seizures disorder 2018 used medication (levitiracetam 500 TID) stopped 3 years back

N/K/O HTN, DM, Asthma, Thyroid

On examination:

Patient is conscious, coherent and cooperative.

Pupils B/L NSRL

Temperature: Afebrile

PR: 84bpm

BP: 100/60mmHg

CVS: S1 S2+, no murmurs

RS: BAE+ NVBS+

P/A: soft , non tender

CNS-

Reflexes Right. Left

B +2. +1

T. +2. +1

S. +2. +1

K. +2. +1

A. +2. +1

Plantar. Flexor. Flexor

Meningeal sign - Absent

Dr.Sushmita (SR)

Dr.Deepika (PG2)

Daily routine: Patient is a house wife wakes up at 6 am, have her breakfast at 8 30 am, does house hold work, have her lunch at 1 pm, take rest for sometime, have dinner at 9pm and goes to bed at 10pm.

Her sleep is disturbed since 1 week due to head ache which is affecting her daily routine

Advice :

Advised for admission to observe further any seizures activity

[28/06, 12:08] +91 79958 46078: Op no : 20230643278

A 63 years old female who is a home maker by occupation came with the chief complaints of left lower limb pain which is dragging type in nature and aggrevates with walking and relieves with rest a/w tingling and numbness of left LLand knee pains since 3 days

There is no history of lifting heavy weights and trauma

Past history : b/L knee pains since last 1 month and increased since last 1 week

K/c/o HTN since 4 years on regular medication

N/K/c/o DM, Epilepsy, TB,Asthma , CAD

On examination:

Pt is c/c/c

No pallor icterus cyanosis clubbing edema lymphadenopathy

Local examination:

SLRT - negative

Left Knee - swelling present

Crepitus - +

NO FFD

Systemic examination : normal

Vitals

BP: 120/60mmHg

PR : 82bpm

Dr. Sushmitha (SR)

Dr. Deepika (pgy2)

Advice:

Physiotherapy

Symptomatic treatment

[28/06, 12:30] +91 92906 89343: OP NO. 20210522428

67 year old male came to the opd with c/o dragging type of pain at neck and lower back radiating to arms and lower limbs since 2 months

Relieved by lying down

Morning stiffness present for 30 min relieved as day progress

H/O usage of medication (unknown) for the same

N/K/C/O HTN, DM, CAD, Thyroid , seizures

On examination:

Patient is conscious, coherent and cooperative.

Neck ROM normal

Knee crepitus positive

Temperature: Afebrile

PR: 78bpm

BP: 110/70mmHg

RR: 18cpm

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Sushmita(SR)

Dr.Deepika (PG2)

Daily routine:

Patient occupation : Tailor

Patient wakes up at 7 am and goes to work at 10 am has lunch at 2 pm, comes back home at 6pm have dinner at 8:30 pm and goes to sleep at 10pm. He stopped going to work since 2 months due to his neck pain and lower back pain. Always prefer lying down

Advice :

Physiotherapy

Symptomatic treatment

[28/06, 14:19] +91 92906 89343: Op no. 20210310067

50 year old male came to opd with c/o lower back ache rt side radiating to loin and abdomen since 6 months

Diagnosed to have ?renal calculi ?fatty liver and was treated conservatively

Pain aggravated since past 20 days

Belching present, distention of abdomen present

C/O polyuria, polydypsia polyphagia

Tingling, numbness and burning feet present

K/C/O DM type II since 11 years on tab

Glycomet GP 3

N/K/O HTN, Thyroid, seizures disorders

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 82bpm

BP: 120/80mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Sushmitha (SR)

Dr.Deepika(PG2)

Daily routine-

Patient occupation - business

Patient wakes up at 7 am and goes to work at 10 am has lunch at 2 pm, comes back home at 8pm have dinner at 9 pm and goes to sleep at 10pm. Since 6 months sometimes he is unable to go for work due to pain

Advice -

Avoid spicy and fatty food

Avoid alcohol

Plenty of oral fluids

Strict Diabetic diet

Symptomatic treatment

[28/06, 14:45] +91 79958 46078: Op no : 20230643300

A 56 year old male who is a framer by occupation came with the chief complaints of left sided chest pain , dragging type and non radiating type of pain since 1 week and shortness of breath (grade -II NYHA) since 15days which is insidious in onset and non progress in nature

Not a/w profuse sweating and palpitations

K/c/o DM since 4 years (on tab. Metformin 500mg/PO/OD

N/k/c/o HTN, epilepsy , asthma , TB, CAD

On examination :

Pt is c/c/c

Bp- 130/80 mmhg

PR- 72bpm

Systemic examination :

CVS- S1 S2 heard

No murmurs

Apex beat felt at 5 th inter coastal space

RS - no abnormalities

CNS- no abnormalities

Dr. Sushmitha (SR)

Dr. Deepika (pgy2)

Advice :

symptomatic treatment

[28/06, 14:53] +91 92906 89343: A 27 year old male came to opd with c/o of pain in right heel and lower back since 6 months

Lower back ache radiating to lower limbs ( dragging type)

Tingling and numbness present

Morning stiffness present

Relieved with medications

N/k/O DM, HTN, Asthma, seizures

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 84bpm

BP: 110/80mmHg

Sternal tenderness present

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Sushmitha (SR)

Dr. Deepika (PG2)

Daily routine-

Patient occupation- mechanic

Patient wakes up at 7 30 am, have breakfast at 9 am, goes to work by 10 30, have his lunch at 2 30 pm, take rest for sometime, go home by 5pm ,have dinner at 10 pm and goes to bed by 11pm.

Since 6 months he is unable to have proper sleep due to lower back pain

Advice -

Physiotherapy lower back

Symptomatic treatment

[28/06, 15:12] +91 92906 89343: Op no: 20230643945

A 31 year old male came to OPD with the c/o fever with chills , cough, body pains since 3 days

H/O cough with sputum

Relieved on taking medications

N/K/C/O HTN,DM,asthma, thyroid disorders, epilepsy, TB.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 78bpm

BP: 110/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr Susmitha (SR)

Dr Deepika (PG2)

Daily routine :

Patient works in eenadu office, daily he goes to work at 3 am on bike. Since 3 days he is taking medications (DOLO650) and continues to go to work

Advice :

Symptomatic treatment

[28/06, 15:25] +91 79958 46078: 20230643308

A 32 year old female

C/o headache which is over parietal region and throbbing type since 1 year on and off .

C/o nausea , vomiting , photophobia , phonophobia , fever , pain abdomen giddiness

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

On examination

Pt is c/c/c

No pallor ,icterus ,cyanosis ,clubbing,lymphadenopathy

CVS S1 S2 heard no murmurs

RS BAE NVBS+

BP: 110/80mmhg

PR: 84bpm

Dr.Sushmitha(SR)

Dr.Deepika(Pgy2)

Advise :

Adequate rest

Symptomatic treatment

[28/06, 15:41] +91 92906 89343: Op no. 20230644464

A 30 year old female came to the opd with the c/o SOB (Grade III) since 3 days a/w chest pain (squeezing type) non radiating

Aggravated after long gap between meals/food

H/o of similar complaints 2 months back

N/K/O HTN, DM, Thyroid, TB, CAD, Epilepsy

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 86bpm

BP: 120/80mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr Sushmitha (SR )

Dr Deepika (PG2)

Daily routine-

Patient occupation - farmer

Patient wakes up at 5 am, have her breakfast at 8 am, does house hold work, and goes for farming , have her lunch at 1 pm, take rest for sometime, reach home by 5 pm and have dinner at 9pm and goes to bed at 10pm.

Patient has a habit of fasting on Mondays or Saturdays

Patient stopped going for farming since 3 days due to SOB and chest pain

Advice -

Small frequent meals

Avoid fasting or long gaps between meals

Avoid spicy food

Symptomatic treatment

[28/06, 15:59] +91 79958 46078: Op no :20230643859

A 70 year old female

C/o burning micturation since 20 days

Reddish discolouration of urine occasionally a/w lower abdominal pain and not a/w decreased urine output, decreased frequency .

K/c/o HTN since 3 months (on medication)

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

On examination

Pt is c/c/c

No pallor ,icterus ,cyanosis ,clubbing,lymphadenopathy

CVS- S1 S2 heard no murmurs

RS -BAE NVBS+

BP-130/80mmhg

PR-72bpm

Dr.Sushmitha (SR)

Dr. Deepika(pgy2)

Advice :

Adequate hydration

Symptomatic treatment

29june2023

[29/06, 10:12] Uha Junior: Op no. 20230645049

A 22 year old male came to the opd with the c/o pain abdomen(left hypochondric pain ) 2 days ago lasted for 30 min

Burning type of pain

Relieved on medication

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 84

BP: 120/80mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr Sushmitha (SR )

Dr Keerthi(PG2)

Daily routine-

Patient occupation - business

Patient wakes up at 6am, have his breakfast at 8 am, go for his business (grocery shop sits at the billing counter)and , have his lunch at 1 pm at the work place itself in his free time at work he watches television and reach home by 8 pm and have dinner at 9pm and goes to bed at 10pm.

Patient daily routine has not changed even after the illness

Advice -

Small frequent meals

Avoid long gaps between meals

Avoid spicy food

Symptomatic treatment

[29/06, 10:41] Rohit Dharma: Op no: 20230644744

A 20 yr old female who is a student came with c/o pain in the Right shoulder since yesterday

Swelling in the rt shoulder, tenderness present, restriction movement is present

C/o pain in the rt hand since 1 week

K/c/o bronchial asthma since 3 yrs on regular medication

On examination

Pt is conscious coherent and cooperative

Temp Afebrile

Bp 110/ 70 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Daily routine - she is a nursing student of our college she wakes up at 6am , and has her breakfast at 7:30 and she comes to hospital and does her work and yesterday she wrote a record for 3 hours from that time she got this complaint.patient daily routine has not changed even after this complaints

Advice

Hot compress

Symptomatic management

[29/06, 11:17] Rohit Dharma: Op no: 20230645158

A 60yr old male came with c/o pain in the epigastric region since 1 week

Non radiating pain

N/K/c/o HTN,DM,asthma,thyriod disorders, CAD,CVA

On examination

Pt is conscious coherent and cooperative

Temp Afebrile

Bp 110/ 70 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Daily routine - he is a auto driver, he wakes up at 6am , and has his breakfast at 8 and he goes for work and he has lunch at 1 pm and dinner at 8 and he will goes to sleep at 10

He will eat more spicy foods twice a day

Advice

Avoid spicy foods

Symptomatic management

[29/06, 11:37] Uha Junior: Op no. 20230645177

A 35 year old female labourer by occupation came with complaints of pain abdomen in left lumbar region and left iliac region since 4 days

Squeezing type of pain,Non radiating,pain aggravated on taking food

C/o burning micturition associated with pain abdomen since 4 days

C/o generalized weakness since 4 days

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 80 bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr Sushmitha (SR )

Dr Keerthi(PG2)

Daily routine-

Patient occupation - daily wage labourer

Patient wakes up around 5 am does household work and have her breakfast at 8 am and goes to work and have her lunch at 1 pm at the place of work and come back home at 5 pm and again does the household work and have dinner at 8pm and sleeps at 10 pm

Patient stopped doing any work since 4 days because of pain

Advice -

Avoid spicy foods

Plenty of fluids intake

Symptomatic management

[29/06, 12:10] Rohit Dharma: Op no: 20210600867

A 46yrs old female came with c/o giddiness since 3 days

C/o neck pain since 3 yrs

H/o of RTA 12 yrs back then small clot in brain as said by patient

H/0 RTA 3 months back since then swaying

N/K/c/o HTN,DM,asthma,thyriod disorders, CAD,CVA

On examination

Pt is conscious coherent and cooperative

Temp Afebrile

supine 120/ 80 mm Hg

Standing 90/60mmhg

CVS S1 S2 +,no murmurs

CNS-

Power - Right left

UL. 5/5. 5/5

LL. 5/5. 5/5

Tone

UL. N. N

LL. N. N

Reflexes Right. Left

B +2. +2

T. +2. +2

S. +1 +1

K. - -

A. - -

Plantar. Flexor. Flexor

RS BAE+,NVBS +

P/A soft,non tender

Cerebellum

Swaying towards left side

Rombergs test - positive

swaying towards left side

Dix hallpik - not able to perform as patient is denying

Postural hypertension is present

Daily routine - she is daily worker at school ayyamma he wakes up at 6am , and has his breakfast at 8 and he goes for work and she has lunch 1pm and dinner at 9 and she will goes to sleep at 10

Patient was affected her daily routine due to neck pain and giddiness since 3 yrs

Patient was Adviced admission for further evaluation

[29/06, 12:31] Rohit Dharma: Op no. 202306454218

A 39 year old female came to the opd with the c/o pain and swelling at right ankle since 1 year

H/o trauma present no tenderness

Pain increased doing work

Tingling sensation of hands and feet

N/K/O HTN, DM, Asthma, Thyroid

On examination:

Patient is conscious, coherent and cooperative.

Pupils B/L NSRL

Temperature: Afebrile

PR: 68bpm

BP: 120/70mmHg

CVS: S1 S2+, no murmurs

RS: BAE+ NVBS+

P/A: soft , non tender

CNS-NFND

Dr.Sushmita (SR)

Dr.keerthi(PG2)

Daily routine: Patient is a farmer wakes up at 6 am, have her breakfast at 8 30 am, goes to work, have her lunch at 1 pm, take rest for sometime, have dinner at 9pm and goes to bed at 10pm.

She stopped working since 1 year ankle pain which is affecting her daily routine

She went for Ortho referral and x ray also done they said there is no fracture

Advice :

Advised physiotherapy

And symptomatic treatment

[29/06, 14:33] Uha Junior: Op no. 20230646173

A 13 yr old child who is student came with complaints of fever since 2 days which is low grade , intermittent not associated with chills and rigor ,

Associated with vomitings since today morning with food as content,non bilious non, projectile,3 episodes

Complaints of stomach pain since today morning

C/o dizziness in the morning since yesterday

On examination:

Patient is conscious, coherent and cooperative.

Temperature: 98.8 F

PR: 80 bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Daily routine

Child stays in hostel

Child wakes up at 6 am have breakfast at 8 am and goes to school at 9 am and comes for lunch at 1 pm and goes back to school and comes back at 4 45 pm and plays for sometime and have dinner at 8 pm and sleeps at 9 pm

Dr Sushmitha (SR )

Dr Keerthi(PG2)

Advice -

Aqeuate hydration

Symptomatic treatment

[29/06, 14:38] Uha Junior: Op no 20230646170

Pt is 18 yr female who is a student

C/o giddiness since 3 days ,

C/o tingling and numbness of both UL and LL

Exertional dyspnea present

O/E:

Pt is c/c/c

Afebrile

Pallor present

Icterus present

PR:86 bpm

BP: 100/60 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Pt was advised for admission but is not willing to admit

Daily routine

Pt wakes up a 6 am takes breakfast at 8 am and goes to clg at 9 am and comes back by 4 pm then she studies upto 8pm have her dinner and sleep by 10 pm

Pt stopped gng to clg since 2 days

Dr.sushmitha (SR)

Dr.kerthi (PGY 2)

Advice:

Symptomatic treatment

[29/06, 14:48] Uha Junior: Op no 20210125543

Pt is 48 yr male who is a weaver by occupation came with c/ bloating sensation since 3 days associated with generalized weakness

O/E:

Pt is c/c/c

Afebrile

Pallor present

Icterus present

PR:78 bpm

BP: 110/60 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Daily routine

Pt wakes up a 6 am and starts his weaving work eats at 11 am and rest for 2 hrs and starts his work at 1 pm upto 3 30 pm have his lunch at 3 30 pm and rests for an hr and starts his work at 4 30 and continue upto 7 and have dinner at 8 pm and sleeps at 10 pm

Pt cannot do his work effectively since 3 days due to generalized weakness

Dr.sushmitha (SR)

Dr.kerthi (PGY 2)

Advice:

Have food at regular intervals

Plenty of fluids intake

Symptomatic treatment

[29/06, 14:49] Uha Junior: Op no 20210125543

Pt is 48 yr male who is a weaver by occupation came with c/ bloating sensation since 3 days associated with generalized weakness

O/E:

Pt is c/c/c

Afebrile

Pallor present

Icterus present

PR:78 bpm

BP: 110/60 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Daily routine

Pt cannot do his work effectively since 3 days due to generalized weakness

Dr.sushmitha (SR)

Dr.kerthi (PGY 2)

Advice:

Have food at regular intervals

Plenty of fluids intake

Symptomatic treatment

[29/06, 14:51] Uha Junior: Op no 20210311571

Pt is 36 yr male

C/o tingling and numbness of both UL and LL since 3 days

Exertional dyspnea present since 5 days

C/o palpitations, chest pain ,orthopnea

O/E:

Pt is c/c/c

Afebrile

PR:80 bpm

BP: 130/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Daily routine

Pt wakes up a 6 am takes breakfast at 7:30 am and goes to work at 8 am and comes back by 4 pm then he have his dinner by 8 pm and sleep by 10 pm

Dr.sushmitha (SR)

Dr.keerthi (PGY2)

Advice:

Symptomatic treatment

[29/06, 15:00] Uha Junior: Op no 20230645131

Pt is 40 yr female

C/o generalized weakness and body pains since 3 years

C/o tingling and numbness of both UL and LL since 6 months

C/o exertional dyspnea present, increased sweating

Pedal edema present, pitting type

K/c/o HTN since 10 years on medication

O/E:

Pt is c/c/c

Afebrile

PR:76 bpm

BP: 120/80 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Daily routine

Pt wakes up at 5 am, do the house hold work till 8:00am and have breakfast at 8:00 am and goes to work at 9 am and have lunch at 1 :00 pm at work , comes back by 5 pm and do the house hold work then have her dinner by 8:30 pm and sleep by 10 pm

Pt is not able to her household work effectively like before since 3 years

Dr.sushmitha (SR)

Dr.keerthi (PGY2)

[29/06, 15:29] Uha Junior: Op no 20230645103

Pt is 35 yr female

C/o neck pain since 1 years

C/o tingling sensation of hands since 3 months

C/o chest pain since 2 weeks

(H/o spicy food intake )

O/E:

Pt is c/c/c

Afebrile

PR:80 bpm

BP: 100/60 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Daily routine

Pt wakes up at 5 am, do the house hold work till 8:00am and have breakfast at 8:00 am and goes to agriculture work at 9 am and have lunch at 1 :00 pm at work , comes back by 5 pm and do the house hold work then have her dinner by 8:30 pm and sleep by 10 pm

Dr.sushmitha (SR)

Dr.keerthi (PGY2)

[29/06, 15:31] Uha Junior: Op no 20230645735

Pt is 60 yr male

C/o swelling of bilateral lower limbs since since 1 month

Relieved on lying down.. aggravating on standing / walking

C/o sob grade II

O/E:

Pt is c/c/c

Afebrile

PR:80 bpm

BP: 100/60 mmHg

CVS:S1S2+,no murmurs

CNS:NAD

RS: BAE+NVBS+

P/A: soft , non tender

Daily routine

Pt wakes up a 6 am takes breakfast at 8:30 am and stays at home then he have his lunch at 1:00 pm then he have his dinner by 8 pm and sleep by 10 pm

PT is not able to do his work like before 1 year

Dr.sushmitha (SR)

Dr.keerthi (PGY2)

[29/06, 16:18] Uha Junior: 35 cases seen sir 1 admission from casualty

30 June 2023

[30/06, 10:23] Harika 2k18 Junior: A 55 year old female patient housewife by occupation came to OPD with c/o neck pain radiating to head since 1 week associated with giddiness lasting for 1-2 hours and sometimes relived on its own,sometimes on taking medication .

Neck pain also radiate to shoulders .

Blurring of vision present.

Pt is a known case of Hypertensive on regular medication,Tab.Amlo 5mg,Tab.Atenolol 50 mg OD.

On Examination:

Temperature -Afebrile

Bp-120/70 mmHg

Pr-60bpm

Rr-18 cpm

Systemic examination:

RS- BAE+,NVBS heard.

No added sounds

Cvs-S1,S2 heard ,no murmurs

Advice:

Symptomatic treatment

Dr Nithin (Pgy1)

Dr.Pavan(Pgy2)

Dr.Nikitha(SR)

Daily routine -

Pt wakes up at 5:30 am does her daily activities in the morning and cooks breakfast,will have breakfast by 9 am and cooks lunch at 11 am ,lunch at 2 pm ,she takes a nap in the afternoon ,she cleans the house ,drinks tea in the evening at 6 pm ,prepares dinner and will take dinner by 9 pm and sleeps by 10 pm.

Her daily routine is not affected by the illness.

[30/06, 10:43] Tejaswi 2k18 Surgery Unit 6: Op no: 20230647020

A 68 yr old male came to the opd with c/o low back ache radiating to both lowerlimbs (right>left)since 4 years. Associated with tingling sensation.

C/o pedal edema since 1-2 years. Extending above the ankle . Releived on lying down and aggravated on walking.

C/o grade ll sob and decreased urine output .

Past:

K/c/o dm ll since 10 years on medication- zoryl mv1 bd

K/c/o htn since 10 years on medication-tab cinod 5 mg bd.

Kc/o CKD since 4 years using tab nodosis, tab ecosprn gold 20 /HS, tab lasix 40 mg bd.

Angioplasty done 4 yrs and 7 yrs back.

On examination:

Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 84bpm

Bp: 160/80 mm Hg

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a: soft, non tender

CNS: nfnd

Dr Nikhitha (sr)

Dr Nithin( Pgy1)

Daily routine:

Occupation: Farmer 4 years ago

Patient wakes up at 6 am , drinks warm water and then tea at 8 am, and drinks Ragi Java at 9 am.Then spends time with neighbour s. Have lunch ( rice) at 2 pm .takes rest after lunch. Drinks tea at 5 pm and then drinks Ragi Java at 8 pm. Sleeps at 9 am .

[30/06, 10:44] Tejaswi 2k18 Surgery Unit 6: Advice: Continue same treatment.

[30/06, 10:48] Harika 2k18 Junior: Op no.20230420218

A 32 year old female patient came to OPD with c/o Generalised weakness ,easy fatiguability,Sob on exertion since 1 week.

C/o Headache since 1 week lasting for 1-2 hours and relieved on itself.

C/o reduced appetite.

C/o pain abdomen squeezing type in the umbilical region .

C/o weight loss since last 4 months.

Menstrual History - Regular cycles,no excessive bleeding

On Examination:

Pallor - present.

No icterus, cyanosis, clubbing, lymphadenopathy, generalised edema.

Temperature -Afebrile

Bp-110/50 mmHg

Pr-70bpm

Rr-20cpm

Systemic examination:

RS- BAE+,NVBS heard.

No added sounds

Cvs-S1,S2 heard ,no murmurs

Advice:

-Iron Supplementation.

Dr Nithin (Pgy1)

Dr.Pavan(Pgy2)

Dr.Nikitha(SR)

Daily routine:

Pt wakes up at 6am does her daily activities in the morning and at times cooks breakfast or cooks rice directly, sends her children to school at 8 :30 am will have breakfast or rice by 9 am ,and cooks lunch at 12 pm , she skips her lunch mostly , bring back her children from school in the evening at 5 pm ,will have tea , cooks dinner by 8 pm and takes dinner by 8:30 and sleeps by 9 pm.

Her daily routine is not affected by the illness.

[30/06, 11:03] Harika 2k18 Junior: Op no-20230647071

A 30 year old female patient came to OPD with c/o Headache - Holocranial on and off since 1 year , throbbing type of pain lasting for 24 hours.

C/o earache since 1 month and was diagnosed with ?CSOM and treatment was given

Neck pain present,Nausea present.

On Examination:

No pallor,icterus, cyanosis, clubbing, lymphadenopathy, generalised edema.

Temperature -Afebrile

Bp-100/70 mmHg

Pr-100bpm

Rr-20cpm

Systemic examination:

RS- BAE+,NVBS heard.

No added sounds

Cvs-S1,S2 heard ,no murmurs

Advice:

Symptomatic treatment

Dr Nithin (Pgy1)

Dr.Pavan(Pgy2)

Dr.Nikitha(SR)

Daily routine:

Pt wakes up at 6:30 am does her daily activities,cleans the house in the morning and cooks breakfast,will have breakfast by 8am and cooks lunch at 12pm ,lunch at 2 pm ,prepares dinner and will take dinner by8 pm and sleeps by9 pm.

Her daily routine is not affected by the illness.

[30/06, 11:06] Tejaswi 2k18 Surgery Unit 6: Op no: 20230647604

A 19 yr old female came to the opd with c/o headache since 2 months. Over temporal region , more during nights.body pains and neck pain since 1 week and giddiness since 5 days.

H/o nausea present.

Tenderness present in the cervical region.

H/o headache- used spectacles for headache previously.

C/o pedal edema since 1-2 years. Extending above the ankle . Releived on lying down and aggravated on walking.

H/o photophobia and phonophobia.

H/o of white vaginal discharge 4-5 back with foul smelling.

On examination:

Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 79bpm

Bp: 100/60 mm Hg

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a: soft, non tender

CNS: nfnd

Dr Sushmitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

Advice: Symptomatic treatment

Daily routine:

Occupation: student

Patient wakes up at 6 am , and then drinks tea at 7 am , goes to college and have lunch at 1 pm ( rice) attends classes in the afternoon. Have snacks at 5 pm and dinner at 8 pm and then sleeps at 10:30 pm.

[30/06, 11:14] Tejaswi 2k18 Surgery Unit 6: Op no: 20230647577

A 53 yr old female came to OPD with c/o burning micturition since 1 month ( on and off)

K/c/o hypothyroidism- usage of medication tab thyroxine - 125 mcg po/od came for follow up.

H/o hysterectomy done 10 years back.

On examination:

Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 80bpm

Bp: 110/70 mm Hg

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a: soft, non tender

CNS: nfnd

Dr Sushmitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

Daily routine:

Occupation: labourer

Patient wakes up at 6 am and gets freshened up by 8 am and have breakfast at 9 am . Goes for work and have lunch(rice) at 2 pm .comes home at 5 pm. Drinks tea at 5:30 pm and have dinner at 8 pm(rice) and sleeps at 9 pm.

[30/06, 11:25] Harika 2k18 Junior: Op no- 20230647116

A 50 year old male patient Upasarpanch by occupation came with c/o pain in both lower limbs since 6 months.

Tingling sensation present

Lowback ache- 1 month

Swelling of both lower limbs since 1 month ,pitting type extending upto knee .

Sob grade 2 since 6 months, increased in the past 1 month.

Facial puffiness since 1 month.

Patient is a known case of Dm-since 19 years and on regular medication,using tab. Met 100 mg+ t.glimi 1 mg Bd

Hypertensive since 15 years,on medication Tab Metoprolol 50 + T.Cilinidipine +tab.Telma 40 mg.

Pt is a smoker stopped 8 months back.( Smoked for 25-30 years), occasional alcoholic.

On Examination:

Temperature -Afebrile

Bp-110/70 mmHg

Pr-82bpm

Rr-20cpm

RS- BAE+,NVBS Heard.

Inspiratory crepts in L IAA,ISA.

CVS-S1,S2 Heard

Adv-

Continue same medication

Limb elevation

Food at regular intervals

Dr Nithin (Pgy1)

Dr.Pavan(Pgy2)

Dr.Nikitha(SR)

Daily routine:

Pt wakes up at 6 am ,does his activities and goes to a walk for 30 minutes and come back home at 7 am ,will have breakfast at 8 am ,goes to work by 9 am to chotuppal, skips his meals due to work (mostly) and come home by 6 pm and consumes alcohol occasionally,and takes dinner by 9 pm and sleeps by 10 pm.

His daily routine is not affected by the illness.

[30/06, 11:30] Tejaswi 2k18 Surgery Unit 6: Op no: 20230647769

A 45 yr old male came to OPD with c/o left upper limb tingling, numbness since 1 week. ( Everyday).

Tingling numbness starts after going to sleep at night.( Present when slept on one side)

K/c/o htn since 1 year. - no usage of medication.

On examination:

Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 80bpm

Bp: 120/70 mm Hg

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a: soft, non tender

CNS: nfnd

No shoulder joint tenderness, no restriction of movement.

Dr Sushmitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

Advice:

- Home bp monitoring.

- Avoid sleeping in the same position for long time.

Daily routine:

Patient wakes up at 6 am and gets freshened up by 8 am and have breakfast at 9 am . Studies books for some time and watching tv. and have lunch(rice) at 1 pm takes rest for sometime in the afternoon. Drinks tea at 5 pm and have dinner at 9pm(rice) and sleeps at 10 pm.

[30/06, 11:32] Harika 2k18 Junior: Op no -20210509499

A 27 year old female patient came to OPD with c/o Headache -left sided since 6 days

Left sided chest pain since 6 days

Headache last for 1 hour and relieved by itself (2-3 episodes per day)

C/o sweating, palpitations, feeling anxious.

On Examination:

No pallor,icterus, cyanosis, clubbing, lymphadenopathy, generalised edema.

Temperature -Afebrile

Bp-90/50 mmHg

Pr-92bpm

Rr-20cpm

Systemic examination:

RS- BAE+,NVBS heard.

No added sounds

Cvs-S1,S2 heard ,no murmurs

Daily routine:

Pt wakes up at 6:30 am does her daily activities in the morning,cleans utensils,cleans house and cooks breakfast,will have breakfast by 9 am ,looks after her children and cooks lunch at 11 am ,lunch at 1 pm , prepare dinner and will take dinner by 9 pm and sleeps by 11 pm.

Patient was an employee in the visa department , stopped working 1 year back to look after her children.

Dr Nithin (Pgy1)

Dr.Pavan(Pgy2)

Dr.Nikitha(SR)

[30/06, 11:33] Harika 2k18 Junior: Advice - Symptomatic treatment.

[30/06, 11:44] Tejaswi 2k18 Surgery Unit 6: Op no: 20210524424

A 22 yr old female came to OPD with c/o difficulty in breathing since 2 weeks on doing regular work.

Aggravates on taking deep inspiration , more during nights.

C/o right sided chest pain since 2 weeks.

C/o abdominal bloating present.

Releived on pantop.

On medication for conceiving

( Tab ovacare - L arginine, folic acid.), Tab dydrogestetone.

On examination:

Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 80bpm

Bp: 110/70 mm Hg

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a: soft, non tender

CNS: nfnd

LE:

No local tenderness and no tachypnpea

Dr Nikhitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

Advice:

- tab pantop 40 mg

- adviced to correlate with frequency of difficulty in breathing with physical work .

Daily routine:

Patient wakes up at 6 am and gets freshened up by 8 am and cooks breakfast and lunch at 9 am. Have breakfast at 9 am and lunch at 1 pm . In between spends time with neighbours. Does household work and then takes nap in the afternoon. Drinks tea at 5 pm and have dinner at 8 pm and sleeps by 9 pm.

[30/06, 12:34] Sowmya Bharadwaj: Op no: 20230647646

A 25 year old female came with c/o holocranial headache radiating to neck since one day intermittently, begins in the afternoon and increases in the night.

Relieves on rest

Phonophobia +

Photophobia -

Patient also c/o difficulty in deep breathing since 3 days.

Patient also c/o foul smelling urine since 1 week

It is associated with suprapubic type of pain.

Not associated with burning micturition, fever, urgency, frequency of micturition.

Patient c/o sleep disturbance since 3 days

She also c/o squeezing type of epigastric pain associated with belching and talking.

No h/o Nausea, vomiting, fever, cold and cough

No h/o blurring of vision

No h/o trauma

N/K/C/O Hypertension, DM, Thyroid disorders, epilepsy, TB, CVA, CAD.

General examination -

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema

Vitals-

Temperature: Afebrile

PR: 78 bpm

BP: 100/70 mmHg

On L/E

Sinusial tenderness+

Systemic examination:

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

The patient was advised for admission, but was was not willing.

Advice given to the patient -

1. Avoid triggers

2. Steam inhalation

3. Adequate rest and symptomatic treatment

Daily routine -

Patient is a housewife and takes care of her both children as they are young.

Wakes up at 7:00 am makes breakfast and eats around 8:00 am

She has lunch at around 1:00 pm

Sleeps for about an hour later

She has dinner at around 9:00 pm

Sleeps at night 11:00 pm

[30/06, 12:42] Sowmya Bharadwaj: Op no: 20230647717

A 62 yr old male came to OPD with c/o altered sleep cycle, cravings for alcohol and cigarette.

One episode of Low grade fever 7 days ago.

Patient had Tremors since childhood and increased after stopping alcohol.

No h/o seizures, vomitings.

Last hospital admission 31/5/23 for 15 days and later went for rehabilitation till 24/6/2023

Now, he came to our OPD today for deaddiction.

Not a k/c/o DM2 , Hypertension, Thyroid disorders, Asthma, TB

Last intake of alcohol - 31/5/23

On examination:

Patient is conscious, coherent, cooperative

Pedal edema present pitting type grade 1

Temp: afebrile

Pr: 108 bpm

Bp: 110/80 mm Hg

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a: soft, non tender

CNS: nfnd

Dr Nikhitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

Advice:

- Patient has been sent to deaddiction center.

Daily routine:

Patient wakes up at 7 am and gets freshened up by 8 am and eats breakfast by 8 am used to go work but stopped recently. He has lunch at 1 pm . Drinks tea at 5 pm and have dinner at 8 pm and sleeps by 9 pm.

[30/06, 14:11] Sreelekha ❤: Op no -20210509499

A 29 year old female patient came to OPD with c/o pedal edema since 10 days.

The edema subsides on walking and increases on sitting for a long time .

No complains of SOB, chest pain, palpitaions, abdominal pain, frothy urine.

K/c/o hypothyroidism on regular medication

K/c/o bronchial asthama since 10 years on regular medication

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

On Examination:

B/l pedal edema present pitting type

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

VITALS

Temperature -Afebrile

Pr: 80bpm

Bp: 110/70 mm Hg

SYSTEMIC EXAMINATION

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a: soft, non tender

CNS: NFND

Advice:

- the is adviced not to sit continuously for a long time and take regular walks in between work.

- continue the current medication

Daily routine:

Patient is a tailor by occupation.

She wakes up at 6 am gets freshened up and cooks breakfast and lunch for her family . She has breakfast at 9 am and lunch at 1 pm . In between this time she sits and stitches clothes. After lunch she again gets back to work. She Drinks tea at 4pm pm and takes rest for 30mins. she ends her work as a tailor at around 7:30pm and prepares dinner. She has dinner at 9:00pm and sleeps by 10:30pm

Dr Nikhitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

[30/06, 14:21] Sreelekha ❤: Op no. 20230647701

A 20 year old male came to the opd with the complains of fever since yesterday.it is not associated with chills or rigor Relieved on taking medication.

C/o cold since 2 day.

C/o cough associated with sputum, mucoid in consistency since 2 day.

Not associated with fever, headache, loose stools, vomitings.

N/K/C/O HTN, DM, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is concious, coherent and cooperative.

VITALS

Temperature: Afebrile

PR: 82 bpm

BP: 110/70 mmHg

SYSTEMIC EXAMINATION :

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

DAILY ROUTINE:

The patient is a college student. He wakes up at 6:30am and gets freshened up and has breakfast. He goes travels to college by bus and reaches by 7:45am. He attends classes from 8am to 3pm and come back home by 4:00pm. He has snacks and spends some time with his friends. He has dinner at 9:00pm and sleeps by 11:00pm

The patient feels very tired due to his symptoms to continue his daily routine and hence came to us.

Advice:

Adequate hydration and proper rest.

Symptomatic treatment

Dr Nikhitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

[30/06, 14:27] Sowmya Bharadwaj: Op no: 2023064776

A 46 year old male came to opd with k/c/o cirrhosis and portal hypertension

Patient is a chronic alcoholic since 20 years

Last intake - 3 days ago

On examination:

Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 106 bpm

Bp: 110/70 mm Hg

Icterus +

No signs of pallor, cyanosis,clubbing and lymphadenopathy.

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/A: Gross distension of abdomen +

No tenderness, local rise of temperature

CNS - NFAD

Tremors+

Dr Nikhitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

Patient has been advised for admission and for further evaluation, ascitic tap.

Patient has agreed for admission.

[30/06, 14:42] Sowmya Bharadwaj: Op no: 20230647666

A 40 year old female cane to opd with c/o giddiness since one year

C/o burning sensation in the epigastrium since one month

C/o neck pain non radiating, intermittent type since 1 week

No h/o ringing sensation in the ear

H/o scorpion bite 1 month ago

On examination:

Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 106 bpm

Bp: 110/70 mm Hg

Pallor +

No signs of icterus, cyanosis,clubbing and lymphadenopathy.

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/A: Gross distension of abdomen +

No tenderness, local rise of temperature

CNS - NFAD

No orthostatic hypotension

Rombergs sign -ve

Finger-nose incoo radiation absent

Finger-finger incoordination absent

Gait - normal

No dysdiadakokinesia

Normal speech

Dix hallpike test- negative

Dr Nikhitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

Patient has been advised for admission but she's not willing.

Advice -

1. Proper balanced diet including jaggery, leafy vegetables (iron rich diet)

2. Avoid spicy food and lying down immediately after food intake

3. Adequate rest , hydration and hydration.

Daily routine -

Patient is a housewife.

Wakes up at 7:00 am makes breakfast and eats around 8:00 am , completes household chores

She prepares and has lunch at around 1:00 pm

Sleeps for about an hour later and watches TV

She drinks tea at around 5:00 pm

She makes and has dinner at around 8:30 pm

Sleeps at night 10:00 pm

[30/06, 14:44] Sreelekha ❤: Op no -20230648126

A 45 year old female patient came to OPD with c/o pedal edema since 2 months.

The edema subsides on sleeping and elevating legs.

No complains of SOB, chest pain, palpitations, abdominal pain, frothy urine.

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

On Examination:

B/l pedal edema present pitting type

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

VITALS

Temperature -Afebrile

Pr: 86 bpm

Bp: 120/80 mm Hg

SYSTEMIC EXAMINATION:

Cvs: S1 S2 heard,No murmurs

Rs: bae+, NVBS heard

P/a: soft, non tender

CNS: NFAD

Daily routine:

Patient is a security guard by occupation.

She wakes up at 5 am in the morning gets freshened up and cooks breakfast and lunch for her family . She goes to work at 7:30am has breakfast at 9 am. she does her rounds and sits on the desk and does her job. Her shift gets over at 9pm and then she goes home.She has dinner at 10:00pm and sleeps by 11:30pm

Advice:

- the is adviced not to sit continuously for a long time and take regular walks in between work.

- Protein rich diet.

Dr Nikhitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

[30/06, 14:54] Sowmya Bharadwaj: Op no: 2023064776

A 58 year old male came to the opd i/v/o High blood pressure, planned for extraction of tooth.

No h/o chest pain, palpitations, blurring of vision, orthopnea, pnd , giddiness, sob, pedal edema.

Not a k/c/o DM2, Asthma TB, epilepsy, Thyroid disorders,CAD and CVA

On examination:

Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 92 bpm

Bp: 140/100 mm Hg

Rr - 18 cpm

No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy.

Cvs: S1 S2 heard,No murmurs

Apex beat - localised in 5th ICS

Rs: blae+, NVBS heard

P/a: soft, non tender, bowels sounds+

CNS - NFAD

Dr Nikhitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

Patient has been advised for admission and for further evaluation but was not willing.

Advice -

1. Home BP monitoring

2. Salt restriction

3. Can be taken up for tooth extraction

[30/06, 16:14] +91 81797 90837: Op no -20230648087

A 47yrs old male came with c/o giddiness and fall one episode 10 days back with loss of consciousness

Up rolling of eye balls with involuntary movements of 4 limbs

N/h/o deviation of mouth ,slurring of speech , frothing from mouth

episodes lasting for 10 mins and recovered with no positional variation

H/o similar episode 5 years back used medication (unknown) for 10 days and stopped

N/c/o weakness of upper limb and lower limbs

Pt is conscious coherent and cooperative

Temp Afebrile

Bp 110/ 70 mm Hg

Pr- 66bpm

CVS S1 S2 +,no murmurs

CNS-

Power - Right left

UL. 5/5. 5/5

LL. 5/5. 5/5

Tone

UL. N. N

LL. N. N

Reflexes Right. Left

B +2. +2

T. +2. +2

S. + +

K. +2 +2

A. +2 +2

Plantar. Flexor. Flexor

RS BAE+,NVBS +

P/A soft,non tender

Advice -

1.Symptomatic treatment

2.Patient is not willing for admission

Daily Routine:

Patient is shopkeeper and Ration shop dealer

Wakes 5 am and goes to shop cleaning and come back to home by 6:30

Drinks Tea daily 7:30 and eats breakfast by 10 am and goes back to shop

Eats lunch by 1pm

Sits at his shop till -10 pm goes back to home by 10pm to have dinner

Takes alcohol occasionally

Dr Nikhitha (SR)

Dr Pavan( Pgy2)

Dr Nithin( Pgy1)

[30/06, 16:44] Prashant: 20230426627

A 56 yrs old male patient came with

C/o pedal edema since 2 days

(Pitting type ,spreading upto ankle )

No c/o chest pain, palpitations,sob, orthopnea, PND

No c/o decreased urine output

No facial puffiness , abdominal distension

Not a k/c/o CVA, CAD ,HTN ,DM,Epilepsy, thyroid disorders

Vitals

BP 100/60 mm Hg

PR 90 bpm

Respiratory system :BAE PRESENT ,Normal vesicular breath sounds heard over B/L lungs fields

No added sounds

CVS :S1,S2 heard

No murmers

CNS

No focal neurological deficits

Personal history

Wakes at 5 Am

Working as Cloth merchant for the past 13 yrs

Keeps standing through out the day from 9 am till 10 pm as a part if his job

Alcoholic since 29 yrs( in the weekends and also at the end of the month when he gets his salary accounting totally for 10 days in a month -90 ml at a occasion)

Doesnt eat after drinking for 2 days

Stays in Cherlapally

Works in nalgonda

Two children - one boy and one girl ( married)

Advise

To keeps the legs elevated with support of pillows at night

To abstain from alcohol intake

And to evaluate for pedal edema

[30/06, 16:49] +91 81797 90837: Op no -20230648190

A 45 year old female patient came to OPD with c/o headache in occipital region radiating to neck posteriorly since 2-3 months

radiating to left shoulder tingling sensation present on neck region and heaviness of head

N/h/o trauma

Headache lasting for 1-2 hours and relieved itself or by medication

Local tenderness present

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

On Examination: Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 72 bpm

Bp: 110/70 mm Hg

Rr - 18 cpm

No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy.

Cvs: S1 S2 heard,No murmurs

Apex beat - localised in 5th ICS

Rs: blae+, NVBS heard

P/a: soft, non tender, bowels sounds+

CNS - NFAD

Advice -

Symptomatic treatment

Daily Routine :

Patient is a farmer but stopped going to farm due to her household works

She lives in joint family along with her son and daughter. Her husband is tractor driver.

Patient wakes up at 5am

At 6am have her breakfast and does household works at home at 1pm she have her lunch at 2 pm

Sleep till 2 pm wakes up at 4pm at 8 pm she haves dinner and sleeps by 10pm

[30/06, 16:49] Prashant: 20210501916

A 52 yr old male came to OPD with

c/o weakness of Right upper limb and lower limb since 25 days

No c/o tingling sensation

H/o fall from bike due to RTA and had head injury with fracture of right parietal bone

Nose bleed was present

H/o loss of consciousness

Giddiness, headache present

Slurring of speech present

Memory disturbances present

C/o slippage of slippers from right leg while walking

Not a k/c/o DM ,HTN,TB ,epilepsy, CAD, thyroid , bronchial asthma

Vitals

BP 100 /60 mm Hg

PR 78 bpm

Respiratory system :BAE PRESENT ,Normal vesicular breath sounds heard over B/L lungs fields

No added sounds

CVS :S1,S2 heard

No murmers

CNS

Upper limb Lower limb

TONE

Right INCREASED NORMAL

Left NORMAL NORMAL

POWER

RIGHT 4/5 5/5

LEFT 4/5 5/5

Reflexes

B T S K A P

Right 3+ 3+ 2+ - - F

Left 2+ 2+ + - - F

Personal history

Alcoholic since 30 yrs( toddy as well as quarter)

Smoking since 30 yrs

Works as daily wage labourer

Advise

Symptomatic treatment

[30/06, 16:55] Lohith Sir Gen Med: 30cases seen. 2amdissions sir

1 JULY2023

[01/07, 10:07] +91 93819 75404: Op no 20230700011

A 39 year old female came to OPD with

C/o -Giddiness since 10 years rotational,tinnitus

No hearing loss

Chest pain-Lt side radiating to left upper limb

Pain is more before eating food and relived after eating food

N/H/o fever ,cough,SOB

N/H/O palpitations, Pedal edema, excessive sweating

K/C/o DM since 1 yr on Tab glimi-m1

On Examination: Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 84 bpm

Bp: 110/70 mm Hg

Rr - 18 cpm

No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy.

Cvs: S1 S2 heard,No murmurs

Apex beat - localised in 5th ICS

Rs: blae+, NVBS heard

P/a: soft, non tender, bowels sounds+

CNS - NFAD

[01/07, 11:26] +91 93819 75404: Op no -20230700976

A 65 yr old Patient came to opd with

C/o-B/L pedal edema since 1 week(used lasilactone for 3 days)

SOB since 2 days progressive grade 2 to grade 3

No seasonal/diurnal variation

No orthopnea

Giddiness is present

N/H/o palpitations

C/o of chest pain since 20 days.not related to food intake

N/H/o - fever ,cough

N/H/O- decreased urine output

Difficulty in moving neck from side to side.pain radiating to B/L upper limb

Chronic smoker since 30 yr(chutta 3-4/day)

H/o of deranged renal profile 1 week ago

K/c/o -HTN SINCE 7 yrs on Tab amlodipine 5 mg po/0D

N/C/o-DM ,CAD,CVA,seizures

Examination: Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 104bpm

Bp: 140/80 mm Hg

Rr - 22cpm

Mild pallor

No signs of , icterus, cyanosis,clubbing and lymphadenopathy.

Cvs: S1 S2 heard,No murmurs

Apex beat - localised in 5th ICS

Rs: blae+, NVBS heard

P/a: soft, non tender, bowels sounds+

CNS - NFAD

Daily routine-

Patient occupation farmer

Patient wake up 6 am ,have breakfast at 9 Am and lunch at 1pm and take restfor some time and dinner at 7 pm and go bed at 10 pm

Patient stopped going for farming since 1 yr due to knee pain and swelling

7yr back he meet with an accident and had a tibia and fibula fracture of Rt leg

H/o varicose veins since 20 yrs

[01/07, 12:09] +91 93819 75404: Op no -20230700979

20 years old patient came to OPD with

C/o-body pains since 3 days

C/o-sore throat since 3 days

C/o- giddiness since 3 days

C/o cough with sputum since morning,scanty and non blood stained

No H/o fever with rashes

No H/o vomitings ,pain abdomen, burning micturition,loose stools

Past h/o -

Not a k/c/o DM,HTN, Thyroid disorders,asthma,TB and epilepsy

On examination

Patient is conscious, coherent and cooperative

Temp-afebrile

Pr-84 BPM

RR-18 cpm

Cvs-s1,s2 heard,no murmurs

RS-BAE +,NVBS heard

P/A-soft,nontender

Advice-

Symptomatic treatment

Advised to take plenty of oral fluids

Daily Routine:

Patient is a nursing student

Daily morning wakes up at 5:30 am and have her breakfast at 7 and goes to her classes at 8 am.

She then have her lunch at 1:00 pm and again attend her classes till evening.she haves her dinner at 8:00 pm and sleeps by 11:30 pm.

From past three days she gets up morning at 7:00 am and goes to bed at 10 :00 pm

[01/07, 12:39] +91 93819 75404: Op no-20230701070

A 50byr old male came to opd with

C/o Generalized weakness since 3 days

Loss of appatite

Weakness in Lt upper limb since 1 day.unable to lift the hand above the level of head

N/H/o- Loss of consious, involuntary movement, fever

Mild Giddiness is present

N/H/o- drooling of saliva,deviation of angle of mouth,blurring of vision

N/H/o-HTN,DM,CAD,Seizures

H/o CVA? 2 yrs ago

K/c/o- CKD

H/o alcohol consumption 3 days back symptoms started after consumption

N/C/o-DM ,CAD,CVA,seizures

Examination: Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 98 bpm

Bp: 100/70 mm Hg

Rr - 18cpm

Mild pallor

No signs of , icterus, cyanosis,clubbing and lymphadenopathy.

Cvs: S1 S2 heard,No murmurs

Apex beat - localised in 5th ICS

Rs: blae+, NVBS heard

P/a: soft, non tender, bowels sounds+

CNS-

Power - Right left

UL. 5/5. 4/5

LL. 5/5. 5/5

Tone

UL. N. N

LL. N. N

Reflexes Right. Left

B +1 +1

T. +1. +1

S. - -

K. +1 +1

A. - -

No nystagmus

Rombergs -ve

Daily routine-

Patient occupation -farmer

Patient wake up 5 am ,have tea at 6Am then eat some rice then goes for farming and come back to home by 1pm and have lunch and take rest for some time and dinner at 7 pm and go bed at 10 pm

From yesterday he is not going for farming because of his LT hand pain and weakness

He is unable to drive his bike since yesterday

Alcoholic since 28 yrs (drink occasionally)

[01/07, 13:46] +91 93819 75404: Op no- 20230700013

A 42 yr old male came to opd with

C/o-came for regular check up

K/c/o-Type 2 DM SINCE 1 YEAR on glimi-m1 po/oD and metformin po/oD

H/o polyphagia, polydipsia

N/H/o-tingling and numbness

N/H/o-fever,cough,burning mitcuration

N/C/o-DM ,CAD,CVA,seizures,thyroid

On Examination:

Patient is conscious coherent and cooperative

Temp-febrile

PR-64 bpm

Rr - 18cpm

Bp-150/100 mm of Hg

Mild pallor

No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy.

Cvs: S1 S2 heard,No murmurs

Apex beat - localised in 5th ICS

Rs: blae+, NVBS heard

P/a: soft, non tender, bowels sounds+

CNS - NFAD

Daily routine-

Patient occupation -labour

Patient wake up 7 am and have breakfast by 9am,go for work and come back by 1pm and have lunch and take some rest and go to bed by 11pm

The patient is unable to do work as earlier he is easily getting fatigue

Personal h/o-

increased appetite

Increased frequency of urination

Takes alcohol occasionally

Advice-Small frequent meals

Avoid spicy food

Symptomatic treatment

[01/07, 14:47] subhramanyam clg: Op no -20230700006

46 years old patient came to OPD with

C/o-tingling and numbness burning sensation in the bilateral palms and soles , occasional neck pains+ , radiating to B/L palms and soles, difficulty in moving neck from side .

No H/o polyphagia, polydypsia, polyuria

Past history-

Not a k/c/o DM,HTN, Thyroid disorders,CAD,asthma, epilepsy

On examination-

Patient is conscious, coherent and cooperative

Temp -afebrile

PR- 68 BPM

Bp-130/80 mm hg

RR-18 cpm

Cvs- s1,s2 heard, no murmurs

RS-BAE +, NVBS

P/A- soft,non tender

CNS-NFAD

Advice-

Symptomatic treatment

Adequate rest

Daily routine:

Patient is a house wife wakes up at morning 5 am then she does her daily chores and house hold works and have her breakfast at 8:00 am .she have her lunch at 1:00 pm . She have tea and snacks at 5:30pm. she have her dinner by 8:00pm and goes to sleep by 9:00pm

[01/07, 14:48] subhramanyam clg: Op no-20230701079

A 40 years old patient came to OPD with

C/o-generalised body pains since 20 days

No h/o fever,cold ,cough

H/o throat pain since 10 days (on antibiotics)

Difficulty in swallowing is present

Past history-

Not a k/c/o- HTN,DM, asthma, epilepsy,thyroid disorders

On examination:

Temperature: afebrile

PR-80 BPM

Bp-110/70 mm hg

RR-17 cpm

Cvs-s1,s2 heard, no murmurs

RS-BAE+,NVBS

P/A- soft , non tender

CNS-NFAD

Advice-

Steam inhalation

Symptomatic treatment

Daily routine:

Patient is a farmer by occupation he daily Wakes up at 6 am and have his breakfast at 9 am( rice and dal) then he goes to work and has his lunch at 1 30 pm and again goes to work if he have any then he have his dinner at 7:00 pm and goes to bed by 8:00 pm

He has difficulty in sleeping from past 10 days

[01/07, 14:48] subhramanyam clg: Op no -20230701077

35 years old patient came to OPD with

C/o-pain and tingling sensation in the bilateral feet since 2 months

No H/o trauma/fall

C/o lower backache occassionally radiating to left lower limb.

Past history-

Known case of Type ll DM since 2 years on medication (TAB GLIMI-M2 )

Not a k/c/o HTN, Thyroid disorders,CAD,asthma, epilepsy

On examination-

Patient is conscious, coherent and cooperative

Temp -afebrile

PR- 96 BPM

Bp-120/80 mm hg

RR-18 cpm

Cvs- s1,s2 heard, no murmurs

RS-BAE +, NVBS

CNS-NFAD

P/A- soft,non tender

Advice-

Symptomatic treatment

Adequate rest

Daily routine:

Patient is a daily wage worker wakes up at morning 6 am then she does her daily chores and house hold works and have her breakfast at 9 : 30 am and goes to work.she have her lunch at 1:30 pm and again goes to work till evening or night.she have her dinner by 8:30 pm and goes to sleep by 9:30 pm

[01/07, 14:59] +91 93819 75404: Op no- 20230701496

A 50 yr old male came to opd with

C/o-chest pain since 2 months.non radiating, retro sternal.

SOB on exertion grade 2

No H/o orthopnea and PND

NO seasonal and diurnal variation

H/o palpitations and Giddiness

No pedal edema

N/H/o -fever,constipation, loose stools

N/C/o-DM ,CAD,CVA,seizures,HTN

Examination: Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 72 bpm

Bp: 110/80 mm Hg

Rr - 18cpm

Mild pallor

No signs of , icterus, cyanosis,clubbing and lymphadenopathy.

Cvs: S1 S2 heard,No murmurs

Apex beat - localised in 5th ICS

Rs: blae+, NVBS heard

P/a: soft, non tender, bowels sounds+

CNS - NFAD

Personal H/o-

He used to consume alcohol occasionally since 1990 and stopped since 2017

He used to smoke bedi occasionally and stopped from 2017

Daily routine-

Patient occupation -motor mechanic

Patient wake up 6 am ,have breakfast at 8Am and goes to work and come back by 1 pm and have lunch .Then goes to work and closes his shop by 6pm and come back to home take rest for some time and have dinner at 8pm and go bed at 11pm

H/o accidental ingestion of pesticides in 2017 for which he was admitted in hospital for 20 days . From then he is not feeling well

[01/07, 15:37] +91 93819 75404: Op no-20230701054

A 68 yr old female came to opd with a

C/O -chest pain since 3 days.Rt and Lt sided

Pain is aggrevated after eating food.

No radiation of pain

C/o decreased urine output since 5 days

H/O burning micturition since 5 days

SOB on exertion grade 2

No orthopnea,PND

C/o Generalized weakness

N/H/o -excessive sweating, palpitations, Pedal edema

N/H/o-cough,constipation, loose stools, pain abdomen

C/o excessive heat extotance

No H/o weight loss

N/C/o-DM ,CAD,CVA,seizures

Examination: Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 96bpm

Bp: 120/70 mm Hg

Rr - 22cpm

Mild pallor

No signs of , icterus, cyanosis,clubbing and lymphadenopathy.

Cvs: S1 S2 heard,No murmurs

Apex beat - localised in 5th ICS

Rs: blae+, NVBS heard

P/a: soft, non tender, bowels sounds+

CNS - NFAD

Daily routine-

Patient occupation -farmer

Patient wake up 6 am ,have breakfast at 9 Am and lunch at 1pm and take rest for some time and dinner at 7 pm and go bed at 10 pm

She stopped going to farming from 5 -6yrs

Past H/o

H/o of fall 2 yrs back and had patella fracture and treated

H/o thyroid disorder( not on medication)

[01/07, 16:12] +91 93819 75404: Op no- 20230700446

35 year old patient came to OPD with

C/o-cold and cough since 3 days

C/o- sore throat since 3 days

Cough is associated with sputum which is scanty,mucoid, whitish,non pungent and non blood stained.

No h/o fever , headache

No h/o pain abdomen, burning micturition, vomitings and loose stools

Past history-

K/c/o of hypothyroidism since 4 months on regular medication (tab thyronorm 100 mcg)

Not a k/c/o of HTN,DM, asthma, epilepsy,cvd

On examination:

Pt is c/c/c

No pallor ,icterus, cyanosis ,clubbing, lympadenopathy

Bp-110/80mmhg

Pr - 80 bpm

RR-18cpm

CVS: S1 s2 heard no murmurs

RS :BAE +

P/A :soft and non tender

CNS :NFND

Advice-

Adequate hydration and rest

Symptomatic treatment

Daily routine:

Patient is a homemaker

She wakes up at 6:00 am and does her daily chores.she has breakfast at 9 :00 am and takes rest till 11: 00 am then she cooks lunch and has lunch at 2:00 pm she goes to walk in evening with her friends. She have her dinner at 8 pm and goes to bed at 10:00 pm.

[01/07, 16:26] +91 93819 75404: Op no- 20230701526

A 50 yr old female came to opd with a

C/o-chest pain since 1 day.pain is aggrevated on consumption of food

Retrosternal,non radiating

Headach since 1 day

No aura,photophobia,phonophobia

Dry cough since 2 days

No diurnal and seasonal variation

N/C/o-DM ,CAD,CVA,seizures,HTN

On Examination-

Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 92 bpm

Bp: 130/80 mm Hg

Rr - 22cpm

Mild pallor

No signs of , icterus, cyanosis,clubbing and lymphadenopathy.

Titubation + since 10 yrs

Cvs: S1 S2 heard,No murmurs

Apex beat - localised in 5th ICS

Rs: blae+, NVBS heard

P/a: soft, non tender, bowels sounds+

CNS - NFAD Daily routine-

Patient occupation-farming

Patient wake up 6 am have some tea and takes care of cattle(goats) . lunch at 1pm and goes for farming and come back by 5 pm take rest for some time and dinner at 7 pm and go bed at 11 pm

The patient is not willing to get admit

[01/07, 16:40] +91 93819 75404: Op no: 20230345168

A 60yr old male came to opd with

c/o pain in the epigastric region since 1 week

Non radiating pain.burning type of sensation

No H/o vomiting, loose stools, constipation

No H/O bloating sensation

No H/o fever,cough

N/K/c/o HTN,DM,asthma,thyriod disorders, CAD,CVA

On examination

Pt is conscious coherent and cooperative

Temp Afebrile

Bp 110/ 70 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Daily routine - he is a farmer, he wakes up at 6am , and has his breakfast at 8 and he goes for work and he has lunch at 1 pm and dinner at 8 and he will goes to sleep at 10

He will eat more spicy food

He drink alcohol occasionally since 30 yrs

He used to smoke occasionally but stopped 10 yrs back

Advice

Avoid spicy foods

Symptomatic management

[01/07, 17:06] Lohith Sir Gen Med: 24cases seen. No admissions sir

3rd July 2023

[03/07, 10:37] +91 88978 84815: Op no 20230702253

45 yr old female with c/o tingling and numbness of upper limb and lower limb since 10 days ,c/o giddiness and body pain since 1 yr

She is a known case of diabetes since 7 yrs and on metformin 500 mg

And came for check up as she hasn't had for 6 months

On examination

Pt is conscious coherent and cooperative

Temp Afebrile

Bp 110/ 70 mm Hg

CVS S1 S2 +,no murmurs

CNS :NAD

RS BAE+,NVBS +

P/A soft,non tender

Daily routine :she is a homemaker she wakes up at 6am , and has her breakfast at 8 and she does household works as cookinv and cleaning and she has lunch at 1 pm and dinner at 8 and she will goes to sleep at 10

And her daily routine has troubled due to giddiness and body pain

Advice

Rest

Diabetic diet is explained

Symptomatic management

[03/07, 11:00] Vandana 2k18: Op no:20210524425

A 35 year old male patient came to pod with c/o b/L calf muscle pain since one month and swelling of both lower limbs and pain is present at the site

He is an alcoholic since 10 years

Smoker since 12 years (2 cigarettes per day )

On examination:

Bp:90/60

Pulse:82

Temperature:afebrile

CVS :s1s2 +

RS:BLAE present

Local examination:

Lower limb :

RT. Left

Tenderness +. +

Swelling. +. +

Local rise of Present

temperature

All peripheral pulsations present.

Patient was unable to walk after 1 min 30 seconds. Complaints of severe pain

Daily routine:

He is a painter by occupation.He wakes up at 7 Am ,and has breakfast at 9 Am and smokes one cigarette , he usually goes to work at 10 Am but now since one month he is not able to go to work because of pain in his calf muscles.lunch at 2pm ,smokes one more cigarette at 5pm in the evening and he has his dinner at 8 pm ,sleeps at 10:30 pm .

Advice :

Avoid smoking

Adviced admission for further evaluation of vascular disease ?PAD

Dr Sushmitha (sr )

Dr Pavani (pgy2 )

Dr Nithin (PGY1)

[03/07, 11:03] Dr. Rakesh biswas: Why and how vascular if all peripheral pulses are normal?

[03/07, 11:05] Vandana 2k18: Pulse is present but feeble sir

And given History of smoking

[03/07, 11:13] Dr. Rakesh biswas: Femoral is also feeble?

Both sides?

[03/07, 11:16] Vandana 2k18: Femoral is good sir

Dorsalis pedis is feeble on both sides

[03/07, 11:52] +91 88978 84815: Op no 20210600885

A 52 yr old female with c/o loss of appetite,loss of wt ,easy fatigued since 5 months

Known case of hypertension since 6 yrs

On telma 40 mg

On examination

Pt is conscious coherent and cooperative

Temp Afebrile

Bp 130/ 70 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Daily routine since 30 yrs - she is a homemaker ,she wakes up at 7 am , and has her breakfast at 8 and does routine household and she has lunch at around 2 to 3 pm and dinner at 9 to 10 pm and she goes to sleep after her remaining works around 12 pm .

Her fatigue causing work delay since 3 months and needed help in doing her routine which made her visit hospital

Advice

Thyroid function tests

Accordingly Symptomatic management

[03/07, 11:54] Vandana 2k18: Op no : 20230702635

23y old female came to op with c/o headache since 20 days lasting for 2-3 hours and relieved by medication.

Associated with vomitings after food intake

2-3 episodes per day - headache .

Patient used medication 1 year back regarding migraine used for one month and stopped .

Right sided headache radiating to neck.

No photophobia or phonophobia .no redness or watery of eyes .

Bp:110/80

Pulse :90bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

She is a homemaker, wakes up at 6 am and does all the household chores , has breakfast at 9 Am and cooks lunch , and eats at 1 pm , and dinner at 7 pm and goes to sleep at 10 pm

But now since 20 days she is is unable to sleep because of headache, not able to do household chores and feels weak because of vomitings. Her daily routine is disturbed.

? Tension headache.

Advice :

Adviced to do meditation and practice yoga

Symptomatic treatment

Dr Sushmitha (sr )

Dr Pavani ( PGY1)

Dr Nithin (pg y2 )

[03/07, 12:20] Vandana 2k18: Op no: 20230703252

19 year male came to op with c/o pain abdomen and loose stools since 2 days

4-5 episodes per day , watery , non mucoid , fowl smelling, associated with pain abdomen.

Squeezing type of pain - umbilical region

No h/0 vomitings, nausea , Fever

No h/0 consumption of outside food

Bp:90/70

Pulse :92bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmur

P/A: tenderness present in umbilical region and hypo gastric region

Daily routine:

Wakes up at 7 Am , has breakfast at 8:Am goes to college, has his lunch at 1pm and comes back home at 5 pm , dinner at 8 pm and sleeps at 10 pm

He is not going to college since 2 days because of pain abdomen and loose stools.

Advice :

Plenty of oral fluids

Symptomatic treatment.

Dr Sushmitha (sr )

Dr Pavani ( PGY1)

Dr Nithin (pg y2 )

[03/07, 12:34] Vandana 2k18: Op no: 20230702279

40 year female came to op with c/0 pain and burning sensation of head since 3 years on and off relieved by medication.

Dragging type of neck pain

No c/o vomiting, giddiness , photophobia,photophobia

Bp:100/70

Pulse :82bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmur

Daily routine:

She is a homemaker, wakes up at 6 am and does all the household chores , has breakfast at 9 Am and cooks lunch , and eats at 1 pm , and dinner at 7 pm and goes to sleep at 10 pm

Because of headache she is not able to household chores and she is not able to wake up in the morning.

Advice :

Rest

Symptomatic treatment.

Dr Sushmitha (sr )

Dr Pavani ( PGY1)

Dr Nithin (pg y2 )

[03/07, 13:34] +91 88978 84815: Op no 20230702583

25 yr female came with

C/o fever since 4 days ,high grade , intermittent

Body pains since 4 days , generalized

Loose stools since yesterday night ,10 episodes

K/c/o hypertension since 2 yrs on medication telma 40+12.5 mg

On examination

Pt is conscious coherent and cooperative

Temp 100 °F

Bp 100/ 60 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Daily routine

She is a sister working 12 hrs per day since 3 yrs ,has break fast at 7 am ,lunch at 2 pm ,dinner at 9 pm and might vary due to work And she feels difficult to work due to complaints .

Dr.Sushmitha (SR)

Dr.Pavani (pgy2)

Advice

Symptomatic management

[03/07, 13:34] +91 88978 84815: Op no 20210521611

19 yr old male pt came with

C/o fever since 2 weeks which is low grade , intermittent ,no diurnal variation

Productive Cough with sputum since 1 week

Daily routine

He is a inter student , hosteller ,wakes at 7 am goes to college 8 am and lunch at 1 pm and dinner at 8 pm ,sleeps at 11 pm .

He is not attending college since 2 weeks

N/K/c/o HTN,DM,asthma,thyriod disorders, CAD,CVA

On examination

Pt is conscious coherent and cooperative

Temp 99° F

Bp 110/ 70 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Advice

Symptomatic management

[03/07, 13:44] +91 88978 84815: Op no20230703779

38 male came with c/o fever since 3 days low grade , intermittent ,

Back pain and headache in b/l temporal region since 2 days

N/k/c htn,dm, epilepsy,asthma,TB.

On examination

Pt is conscious coherent and cooperative

Temp 99°f

Bp 110/ 70 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Daily routine

He is an electrician since 10 yrs goes for work at 9 am and does till 6 pm has breakfast at 8 am ,lunch 2 pm ,dinner at 9 pm .

His work is not disturbed due to complaints

Dr.Sushmitha (sr)

Dr.pavani (pgy2)

Advice

Symptomatic treatment

[03/07, 14:02] Vandana 2k18: 34 year old female came to op with c/o weight gain and increase appetite since past 2 months

Associated with Excessive hair loss ,palpitations, easy fatiguability , sob grade 2 mmrc

No h/o constipation,loose stools , fever .

Bp:110/80

Pulse :87bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

She is a homemaker, wakes up at 6 am and does all the household chores , has breakfast at 8Am and cooks lunch , and eats at 1 pm , she drinks tea at 5 pm and dinner at 9pm and goes to sleep at 11 pm

Her daily routine is not much affected,but her concern is about weight gain .

Advice :

Good diet and regular exercise

Symptomatic treatment.

Dr Sushmitha (sr )

Dr Pavani ( PGY1)

Dr Nithin (pg y2 )

[03/07, 14:27] +91 88978 84815: Op no 20230703246

50 y female Pt c/o burning sensation in chest region since 2 yrs

H/o stomach pain and tightness since 2 yrs in lower quadrant ,h/o indigestion , bloating

Aggravated on eating spicy food ,

H/o constipation present since 2 yrs

H/o generalised weakness since 5yrs

H/o frequent urination since 2 months

H/o toddy intake since 20 yrs

N/k/c htn,dm,asthma, epilepsy ,TB,CVA,cad

On examination

Pt is conscious coherent and cooperative

Temp afebrile

Bp 100/ 70 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Dr.Sushmitha (Sr)

Dr.Pavani (pgy2)

Advice

Avoid spicy food

Fibre Food diet

Symptomatic treatment

[03/07, 14:34] +91 88978 84815: Op no 20230703285

65 yr male came with complaints of giddiness since 1 week associated with headache and nausea

K/c /o hypertension since 15 yrs on AMLODIPINE 5 mg

On examination

Pt is conscious coherent and cooperative

Temp afebrile

Bp 120/ 90 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Daily routine

Pt is not working since 5 yrs due to old age and depends on his son ,wakes at 7 am has breakfast 8 am ,lunch 2pm , dinner 8 pm ,sleeps at 9 pm ,takes rest in between sometimes has toddy

Due to present complaints he needs help in daily life activities .

Advice

Rest

Symptomatic treatment

[03/07, 14:40] Vandana 2k18: Op no : 20230703215

20 year old female came to op with c/o vomitings since 4 days mucoid , non projectile, non bilious , non blood stained .

Abdominal bloating is present

Associated with low grade fever on and off since 4 days relieved on medication , associated with decreased appetite

Not associated with cough,cold , constipation.

Bp:110/80

Pulse :90bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

Wakes up at 6Am , has breakfast at 8:Am goes to college, has her lunch at 1pm and comes back home at 5 pm , dinner at 8 pm and sleeps at 10 pm

She is not going to college since 2 days because of vomitings.

Advice :

Rest

Symptomatic treatment.

Dr Sushmitha (sr )

Dr Pavani ( PGY1)

Dr Nithin (pg y2 )

[03/07, 14:44] +91 88978 84815: Op no 20230703271

35 yr male complaints of giddiness since 1 week associated with headache , aggravated on sudden rise from sitting ,nausea and photophobia are also present

Not a k/c/o htn,dm,asthma,cad, epilepsy

On examination

Pt is conscious coherent and cooperative

Temp afebrile

Bp 120/ 70 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Daily routine

She is a tailor working from 8 to 8 pm. Along with household activities

Wakes up at 7 am ,has breakfast and lunch at 2 pm and dinner at 9 pm ,sleeps at 10 pm

Advice

Symptomatic treatment

[03/07, 15:20] +91 88978 84815: Op no 20230703239

31 yr female

C/o b/l pedal edema since 1 yr pitting type ,reduces on lifting legs

Tingling and numbness of both lower limbs

H/o irregular periods, last period in April 12

K/c/o hypothyroidism

Daily routine

She is in job hunting since 3 yrs and wakes at 6 am ,sleeps at 12 pm ,studies in between

Her routine isn't much affected

On examination

Pt is conscious coherent and cooperative

Temp 99°f

Bp 90/ 60 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Advice

Thyroid function test

Symptomatic treatment

[03/07, 15:28] +91 88978 84815: Op no 20230703243.

49 yr old female c/o pain abdomen in epigastric region since 5 days aggravated by intake of food

N/k/c/o htn ,dm, asthma,tb

Daily routine

He is a daily wage labourer and works 8 to 5 pm and has breakfast at 8 am,lunch at 1 pm ,dinner at 7pm ,sleeps at 8 pm

On examination

Pt is conscious coherent and cooperative

Temp afebrile

Bp 90/ 60 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Advice

Avoid spicy food

Symptomatic treatment

[03/07, 15:37] +91 88978 84815: Op no 20230702249

70 yr female c/o chest pain since 15 days radiating to left hand not associated with sweating and palpitations

C/o Sob since 15 days ,mmrc 1

H/o cad ,on tab ecospirin and torsemide

H/o htn since 2 yrs on medication tab .nicardia 10 mg

On examination

Pt is conscious coherent and cooperative

Temp afebrile

Bp 160/90 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Advice

Rest

Symptomatic treatment

[03/07, 15:44] +91 88978 84815: Op no20230703779

20 yr female came with c/o fever since 4 days high grade , intermittent ,with chills and rigor

C/o vomitings 3 episodes yesterday ,now subsided ,c/o stomach pain and tightness since 2 days

Loose stools ,watery in consistency from yesterday 10 to 15 episodes

N/k/c htn,dm, epilepsy,asthma,TB.

On examination

Pt is conscious coherent and cooperative

Temp 100°f

Bp 100/ 60 mm Hg

CVS S1 S2 +,no murmurs

CNS NAD

RS BAE+,NVBS +

P/A soft,non tender

Daily routine

She is a student studying nursing since 3 yr

Goes to clg and leaves by 5 pm and sleeps at 11 pm .

Dr.Sushmitha (sr)

Dr.pavani (pgy2)

Advice

hygeinic Food

Symptomatic treatment

[03/07, 15:58] Vandana 2k18: Op no : 20230703285

65 year old male came with c/o of giddiness from one week associated with headache and nausea

No h/o photophobia and phonophobia

He is k/c/o hypertension and he is on tab amlodipine since 6 years

Bp:110/80

Pulse :87bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

He wakes up at 6 am on the morning and has his breakfast at 8 Am and goes to field work and comes back at 1 pm has lunch and takes a nap for 1 hour. He has his dinner at 7 pm and goes to bed by 9 pm

Since one week he is not going to field work he is taking rest at home .

Advice :

Adviced good diet

Rest

Symptomatic treatment

Dr Sushmitha (sr )

Dr Pavani ( PGY1)

Dr Nithin (pg y2 )

[03/07, 16:17] Vandana 2k18: Op no : 20210526892

61 y old female came to op with c/o numbness and tingling sensation of both hands during sleep since 6 months

No c/o nausea ,vomitings,sob , epigastric pain , palpitations and orthopnoea

Normal appetite

Bp:100/60

Pulse :90bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

She is a homemaker, wakes up at 5 am and does all the household chores , has breakfast at 8Am and cooks lunch , and eats at 1 pm and dinner at 9pm and goes to sleep at 9 pm her daily routine is not much affected.

Advice :

Adviced good diet

Rest

Symptomatic treatment.

Dr Sushmitha (sr )

Dr Pavani ( PGY1)

Dr Nithin (pg y2 )

[03/07, 16:28] Dr. Rakesh biswas: What kind of help does he need in his daily activities?

[03/07, 16:30] +91 88978 84815: To support the patient from falling due to giddiness

[03/07, 16:36] Dr. Rakesh biswas: Is he able to do any work?

Did they get admitted?

[03/07, 16:41] +91 88978 84815: Apparently he is not doing any work

Just daily life activities as eating and etc

He is not willing to admit sir

[03/07, 16:43] Dr. Rakesh biswas: What were they expecting from this opd visit?

[03/07, 16:44] +91 88978 84815: Their expectations were any tests related and medicines to improve the condition

4th July 2023

[04/07, 09:47] Sravani: Op no : 20230704108

65 y old male came to op with c/o cough which is productive , mucoid in nature Since 5 months

H/o ATT medication for 6 months.

Tingling of b/l lower limbs since 6 months

Bp:90/60

Pulse :68bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

He used to work in rice mill 6 months back due to cough he stopped going to work. Before 6 months he used to wake up at 5 am and has breakfast at 8Am and goes and works in mill , and eats at 1 pm and comes back home at 6 pm and watches TV and has dinner at 9pm and goes to sleep at 10 pm his daily routine got affected because of cough and being unable to do much work he stopped going to to work and is staying at home since then.

Advice :

Adviced good diet

Rest

Symptomatic treatment.

Dr Nikhitha (sr )

Dr lohith ( PGY1)

Dr Hari priya (pg y2 )

[04/07, 10:02] Sravani: Op no : 20210511730

24 y old male came to op with c/o fever (high grade) with chills ,continuous in nature relieved on taking medication.

H/o an episode of vomiting with food as content.

H/o loose stools (4 episodes )

Pain abdomen +

No h/o cold,cough, burning micturation,maculopapular rash-

Bp:150/70

Pulse :90bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

He is a barber , wakes up at 7am and has breakfast at 8Am and goes to baber shop, and eats at 1 pm and dinner at 10pm and goes to sleep at 12 pm his daily routine is not much affected.

Advice :

Adviced good diet

Rest

Symptomatic treatment.

Dr Nikhitha (SR )

Dr Lohith ( PGY1)

Dr Hari priya (pg y2 )

[04/07, 10:12] lokesh reddy12141: OP:20230704478

65 yr old male came to op with c/o of SOB since 2 months ( grade 3)

B/L pedal edema which is pitting type till knee since 2 months

Orthopnea:6months

PND:6months

Decreased urine output ,no h/o burning micturition

Vitals

BP:90/60mmhg

Pulse: 66bpm

Temp:afebrile

CVS:s1 s2 heard no added sounds

RS:NVBS

No h/o of HTN, DM,Asthma, epilepsy etc

Daily routine: Previously when he was healthy he used to wake up early by 5 am and used to go for field work but recently he is not able to do field work and now he used to wake up at around 7am

Advice:

Good diet

Adequate rest

Symptomatic treatment

Nikitha (sr)

Haripriya(pg2yr)

Lohith varma (pg1yr)

[04/07, 10:20] Sravani: Op no : 20210314262

32 y old female came to op with c/o pricking type of pain of left scalp since 5 months

H/o photophobia

No h/o phonophobia, vomitings, seizures

CT brain showed right calcified granuloma.

Bp:120/70

Pulse :80bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

She is a homemaker, wakes up at 6am and does all the household chores , has breakfast at 8Am and cooks lunch , and eats at 1 pm and dinner at 9pm and goes to sleep at 10 pm her daily routine is not much affected.

Advice :

Adviced good diet

Symptomatic treatment.

Dr Nikhitha (SR )

Dr Lohith ( PGY1)

Dr Hari priya (pg y2 )

[04/07, 10:54] lokesh reddy12141: OP:20210514560

48 yr old male came to op with

c/o of burning micturition since 1 month without decreased in urine output without facial puffiness and pedal edema

Not a known case of HTN,DM, epilepsy,asthma etc

Vitals

BP:130/90mmhg

Pulse: 72bpm

Temp:afebrile

CVS:s1 s2 heard no added sounds

Daily routine: He used to wake up around 6am and goes to work at around 8'0 clock there is no disturbance in daily routine activities

Advice:

Plenty of oral fluids

Symptomatic management

Nikitha (sr)

Haripriya(pg2yr)

[04/07, 11:01] Sravani: Op no : 20210705104

19 y old male came to op with c/o cough since 3days associated with sputum which is white in color and non blood tinged

H/o cold 2 weeks back seasonal changes

No h/o fever

No difficulty in breathing

Bp:130/70

Pulse :79bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

He is a student, wakes up at 7am and has breakfast at 8Am and goes to college , and eats at 1 pm and comes back to hostel at 5 pm and has dinner at 9pm and goes

Advice :

Anti histaminics

Dr Hari priya (pg y2 )

[04/07, 11:04] Vishnubharath: Op no : 20230704563

65 y old female came to op with c/o low back ache dragging type of pain radiating down to the leg since 20 days and aggravated on bending relieved on rest

C/o bilateral shoulder pain since 20 days which is non radiating

Hypertension since 6 years and on medication(Tab Atenolol 50mg+amlodipine 5mg)

Not a k/c/o DM,TB,asthama,epilepsy,thyroid disorders

Bp:120/70

Pulse :78bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

O/E:

B/L shoulder no tenderness noted over the joint

No restriction of the movements

No tenderness of the spine

No restriction of movement of hip joint,ankle joint and metatarsal joint

Daily routine:

She is a homemaker, wakes up at 6am and does all the household chores , has breakfast at 8Am and cooks lunch , and eats at 1 pm and dinner at 8pm and goes to sleep at 9pm her daily routine is not much affected.

Advice :

Physipotherapy

Rest

Symptomatic treatment.

Dr Nikhitha (SR )

Dr Harika( PGY1)

Dr Hari priya (pg y2 )

[04/07, 11:39] Sravani: Op no : 20230704502

55 year old female came to op with c/o

B/l hip pain since 1 week which is of dragging type

H/o slippage of foot and fall

Associated with swelling around ankle

Decreased appetite and associated with nausea on eating food.

No h/o bloating and belching

Bp:110/70mmhg

Pulse :79bpm

On examination:

Antalgic Gait and mild waddling to the right.

Straight leg raising test negative

Pain during hip adduction and extension

Daily routine:

Advice :

For hip x ray for any fracture

Dr Nikhitha (SR)

Dr Hari priya (pg y2)

[04/07, 11:44] lokesh reddy12141: OP:20230704613

65yr old female came to op with

c/o of pain in the left middle toe since 2 months which is thrombing type of pain . tingling and burning sensation of palms and soles since 2 months(first bleb present later burst of bleb seen on left toe)

Discoloration of toe insidious in onset gradually in progression

Left eye cataract surgery 4yrs back

K/c/o of DM type 2 since 15yrs and on medication ( metformin and glimiperide)

K/c/o of HTN since 8yrs on medication (amlong)

Dragging of foot present

Negative h/o seizures,asthma ,cad etc

Vitals

BP:130/70mmhg

Pulse: 72bpm

Temp:afebrile

CVS:s1 s2 heard no added sounds

Local examination

Blackish discoloration of left middle toe

Surface:hard

Temp:cold

Distal pulses : dorsalis pedis artery pulsation present

Fine touch and crude touch present

Provisional diagnosis:BL symmetrical sensory peripheral neuropathy with diabetic foot

Advice:

Opinion of surgery i/v/o of diabetic foot

Nikitha (sr)

Haripriya(pg2yr)

[04/07, 12:02] Vishnubharath: Op no : 20230618453

50y old female came to op with c/o cough since 2 months occasionally associated with sputum which is mucoid and non blood tinged

C/o weight loss and loss of appetite since 1 month

Last episode of fever was 15 days ago which is of low grade

Patient c/o burning micturition since 10 days

No c/o sob,orthopnea,pnd,chest pain

K/c/o dyspepsia secondary to gerd and on medication(Tab pan 40 mg po/od)

Not a k/c/o HTN,DM,asthama,epilepsy,thyroid disorders

Bp:90/60mmHg

Pulse :72bpm

RR:26cpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

P/A:soft,non tender,no organomegaly

Daily routine:

She is a homemaker, wakes up at 5am and does all the household chores , has breakfast at 8Am and goes for field work and eats at 1 pm and dinner at 8pm and goes to sleep at 9pm her daily routine is not much affected.

Advice :

Patient advised to admit but not willing for admission

Dr Nikhitha (SR )

Dr Harika( PGY1)

Dr Hari priya (pg y2 )

[04/07, 12:30] lokesh reddy12141: OP:20230705125

30yr old male came to op with

c/o of tingling sensation in b/l soles since 15days

On and off for every 2days relieved on walking

Pricking type of pain in left chest which is intermittent type relieved on its own since 1 month

No h/o of SOB, palpation,lower backache,cough and cold

Negative h/o HTN,DM ,seizures, epilepsy asthma etc

Vitals

BP:100/60mmhg

Pulse: 82bpm

Temp:afebrile

CVS:s1, s2+

CNS examination:

Pupils NSRL

Tone- Normal in all four limbs

Power -

Rt Lt

UL 5/5 5/5

LL 5/5 5/5

Reflexes

Rt. Lt

B +2. +2

T +2. +2

A +2 +2

K +2 +2

Plantar. Rt: flexors. Lt: flexor

Provisional diagnosis:b/l symmetrical sensory peripheral neuropathy secondary to vit b12

Advise:

Dietary modification

Haripriya pg2yr

[04/07, 12:52] Vishnubharath: Op no : 20230705185

40yr old female came to op with c/o right leg pain since 10 days,pain is upto knee which is tingling type of pain

Pain aggravated on working and relieved on rest

No complaints in the opposite leg

Complaints of abdominal pain in left lower quadrant since 1year which is non radiating

H/o belching since 6 months

No h/o nausea and chest pain

Not a k/c/o HTN,DM,asthama,epilepsy,thyroid disorders

Bp:110/70mmHg

Pulse :82bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

P/A:soft,tenderness noted in left iliac fossa region

Daily routine:

She is a tailor by occupation, wakes up at 6am and does all the household chores , has breakfast at 8Am and eats at 1 pm and dinner at 8pm and goes to sleep at 10pm her daily routine is affected couldn’t perform her daily routine

Advise:

Physiotherapy

USG-abdomen and pelvis

Rest

Dr Nikhitha (SR )

Dr Harika( PGY1)

Dr Hari priya (pg y2 )

[04/07, 12:52] Sravani: Op no : 20210526892

30 y old female came to op with c/o pain in the left side chest since 3 days which is of burning type and continuous in nature and not aggravated on food intake relieved on its own

Radiating to the left hand and back.

No h/o bloating and belching

Not associated with vomitings, sob , palpitations and orthopnoea

Bp:90/60

Pulse :88bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

She is a homemaker, wakes up at 7am and does all the household chores , has breakfast at 8Am and cooks lunch , and eats at 1 pm and dinner at 9pm and goes to sleep at 11pm her daily routine is not much affected.

Advice :

Adviced for ecg to rule out MI

Dr Hari priya (pg y2 )

[04/07, 13:12] Sravani: Op no : 20230705106

18y old female came to op with c/o chest pain in the left hypochondrium since 1 year which is of burning type and intermittent in nature and aggravated on taking spicy food and relieved on taking rest.

Belching + and bloating+

Appetite normal

Breathless after eating food

Bp:110/60

Pulse :90bpm

Afebrile

P/A: Soft and non tender

Daily routine:

She is a student, wakes up at 7am and has breakfast at 8Am and goes to college , and eats at 1 pm and comes back to hostel at 5 pm and has dinner at 9pm and goes to sleep at 11 pm her daily routine is not much affected.

Advice :

Symptomatic management

Dr Hari priya (pg y2 )

[04/07, 14:32] Sravani: Op no : 20230705681

52y old male came to op with c/o fever with chills since yesterday night which is intermittent and

No H/o cough and cold and burning micturation

H/o Loss of appetite and Weight loss of 8 kgs in 1 month

Generalised weakness and easy fatiguibility

H/o drowsiness during day time

H/o jaundice 20 days back he also had fever 20 days back and subsided.

Alcohol consumption 4-5times a month since 10 years

Bp:130/70mm hg

Pulse :64bpm

Afebrile

P/A: Soft and non tender

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

He does centring work , wakes up at 6 am has breakfast at 9amand goes to work , and eats at 3 pm and dinner at 8pm and goes to sleep at 11pm his daily routine is not much affected

Advice :

Symptomatic management

Dr Hari priya (pg y2 )

[04/07, 14:41] lokesh reddy12141: OP:20210526783

56yr old male came to op with

c/o of b/l chest pain since 3 days(more in night than morning)

Increased sweating+

No h/o weight lifting ,sob,trauma , palpitations

No aggrevating or relieving factors

H/o of jaundice 20 days back

Alcohol consumption 4-5 times a month

Vitals

BP:120/80mmhg

Pulse: 72bpm

Temp:afebrile

CVS:s1, s2+

Daily routine:he wakes up around 5am and does his routine activity but recently (past 3 days)he is feeling chest pain during night time causing sleep disturbances

Advise:

Symptomatic mgt

Haripriya(pg2yr)

[04/07, 14:42] Vishnubharath: Op no : 20230705246

35yr old female came to op

K/c/o hypothyroidism since 6 years last checked TFT 3 months ago and on tab.thyroxine 25mcg

No E/O hair loss,weight gain in last 3 months

C/o head ache since 3 months which is relieved on taking medication

C/o joint pains since 15 days and on unknown medication

C/o SOB since 15 days grade II NYHA

Not associated with chest pain,orthopnea,PND,palpitations

Not associated with pedal edema,decreased urinary output

K/c/o dyspepsia since 1 year and on medication (Tab.pan 40mg po/od)

Not a k/c/o HTN,DM,asthama,epilepsy,cva,cad

Bp:120/80mmHg

Pulse :78bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

P/A:soft,non tender

Daily routine:

She is a homemaker, wakes up at 6am and does all the household chores , has breakfast at 8Am and cooks food and eats at 1 pm and dinner at 8pm and goes to sleep at 9pm her daily routine is not much affected.

Advice :

TFT

Symptomatic management

Dr Nikhitha (SR )

Dr Harika( PGY1)

Dr Hari priya (pg y2 )

[04/07, 14:57] lokesh reddy12141: Op no :20230705155

50 year female came to op with c/o back pain since one month dragging type radiating to abdomen persistent relieved on sitting associated with intermittent tingling sensation in the left lower leg

K/c/o hypothyroidism since 10 years on tab thyronorm 75 mcg po/od

Bp:110/80

Pulse :87bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

She is a homemaker, wakes up at 6 am and does all the household chores , has breakfast at 8Am and cooks lunch , and eats at 1 pm , and dinner at 8pm and goes to sleep at 10 pm

Her daily routine is not much affected because of Illnesses.

Advice :

Adviced good diet

Rest

Symptomatic treatment.

Dr harika pg 1yr

[04/07, 15:10] Sravani: Op no : 20230705117

50year old female came to op with c/o giddiness on getting up standing since 3 days.

Bp:120/80mmhg(on supine) to 100/60mmhg( on standing )

Pulse :76bpm

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

Daily routine:

She is a homemaker, wakes up at 4am and does all the household chores , has breakfast at 7am and has lunch eats at 1 pm and dinner at 7pm and goes to sleep at 9pm her daily routine is not much affected.

Advice :

Not to change her positions suddenly from supine to standing. Adviced her to sit for a minute and then stand.

Dr Harika (pg1)

[04/07, 15:44] lokesh reddy12141: Op no :20230704522

45 year old female came to op with c/o generalised weakness since 20 days ,decreased appetite since one month

No h/o burning micturation , Fever , cough, excessive sweating,heat intolerance

No h/o bleeding per rectum

On examination:

Bp:90/60

PR :100 bpm

Afebrile

RS:BLAE + ,NVBS + , no added sounds

CVS :s1s2 + no murmurs

P/A:

Soft , non tender

No palpable mass

Lymph nodes not palpable

Daily routine:

She is a homemaker, wakes up at 6am and cooks , has tea around 8 am has breakfast at 9 am and cooks lunch , and eats at 1 pm and dinner at 9pm and goes to sleep at 10pm her daily routine is not much affected.

Since past 20 days she is not doing her daily chores , not eating properly because of lack of appetite.

Advice :

TFT

Symptomatic treatment.

Dr Hari Priya (pg y2)

[04/07, 22:01] Lohith Sir Gen Med: 30-35 cases seen sir.

3 admissions in OPD.

1 admission in casualty sir

5th July 2023

[05/07, 10:35] +91 93924 39427: Op no. 20210507279

34 year old female came to opd with c/o burning sensation of abdomen after having spicy food since 3-4 months

Relieved temporarily on Syrup. Sucrafyl P/O TID

Complains of tingling sensation of lower limbs

N/K/O HTN, DM, Thyroid, seizures disorders

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 78bpm

BP: 120/80mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Diagnosis? Peptic Ulcer disease

Dr.Zain (SR)

Dr. Narsimha (PG 2)

Dr.Lohith(PG1)

Daily routine-

Patient occupation - Tailoring

Patient wakes up at 7 am and has breakfast at 8 am, has lunch at 2 pm, has dinner at 8pm and goes to sleep at 10pm.Since 3-4months she is unable to sleep well at night due to burning sensation which is affecting her work in the daytime

Advice -

Avoid spicy and tangy food

[05/07, 10:40] +91 92906 89343: Op no. 20230705996

A 40 year old male came to the opd with the c/o cough since 3 days

C/o sore throat since 3 days

No h/o of similar complaints in the past

N/K/O HTN, DM, Thyroid, TB, CAD, Epilepsy

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 98bpm

BP: 140/90mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Diagnosis : URTI

Dr zain (SR)

Dr narsimha (PG2)

Dr lohit (PGY 1)

Daily routine-

Patient occupation - weaver

Patient wakes up at 4 am, starts his weaving work by 5 am have his breakfast at 8 am, have his lunch at 1 pm, and does his weaving work till 8pm. Have his dinner at 9pm and goes to sleep by 10pm. Since 3 days he is unable to sleep due to cough.

Advice -

Advised admission but not willing for admission

[05/07, 11:26] +91 93924 39427: Op no. 20230706492

A 26 year old female came to the opd with the c/o headache since 1week

Diffuse headache, throbbing headache, more during evenings, aggravated on watching tv, using mobile.

Relieved after sleep

Phonophobia +

Photophobia+

K/C/O Seizure disorder since 6months

1st episode - 6 months ago

2nd episode -5 days ago

On medication Tab. LEVIPIL 500mg P/O B/D

N/K/O HTN, DM, Thyroid, TB, CAD, Epilepsy

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 72bpm

BP: 120/80mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Diagnosis ? Migraine

Dr.Zain (SR)

Dr. Narsimha (PG2)

Dr.Lohit (PGY 1)

Daily routine-

Patient occupation - Housewife

Patient wakes up at 7 am, has breakfast at 8 am, Dinner at 9pm and goes to sleep by 10pm. Since 1week she's not able to do housechores due to headache and takes rest frequently

Advice -

Symptomatic treatment for Headache

[05/07, 11:27] +91 92906 89343: Op no. 20210320149

52 year old male came to opd with the c/o burning and Tingling sensation of feet since 1 month

C/o polyuria, polydypsia, nocturia

K/c/o type 2 DM since 8 years on

Tab glycomet mv2 / po / od

Tab sitaday M 50 / po / od

N/K/O HTN, Thyroid, seizures disorders

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 82bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr zain (SR)

Dr Narsimha ( PGY2)

Dr lohit ( PGY1)

Daily routine-

Patient occupation - auto driver

Patient wakes up at 6 am, have breakfast and goes to work by 7 am has lunch at 2 pm, and drives auto till 5 pm comes back home. Have dinner by 9 pm and goes to sleep by 10pm.

When patient was non diabetic use to work in a company since Patient got diagnosed with diabetes (8years ago) Patient is unable to work in the company due stress in work place and

Started driving auto from 8 years. Since 1 month he is unable to sleep properly due to burning and Tingling sensation in the feet

Advice -

Strict Diabetic diet

[05/07, 11:29] +91 92906 89343: Op no: 20230706006

A 30 year-old female patient presented with complains of

Tingling sensation in upper and lower limb since 1 year

Which was intermittent,associated with neck pain,aggrevated when pt is tensed

Relieved temporarily on medication

C/o weakness present since 3 months

N/k/c/of HTN,diabetes,epilepsy, thyroid disorders,asthma

General examination:

Pt is consious,coherent,cooperative

BP:110/70mmhg

PR: 78

CVS: s1s2 heard,no murmurs

RS: BAE+ NVBS+

P/A: soft, non tender

Pt was advised for admission but is not willing to admit

Daily routine: she wakes up at 5:30 am ,does all the household chores ,eats at 8:00 am and leaves for work at 8:30 .she’s a agricultural labourer.has her lunch at the work site at around 1:00pm and returns home at 7:00pm and has dinner and goes fo sleep by 10:00pm

Her work is slightly effected due to the weakness since 2 months

Dr.zain alam (SR)

Dr.narsimha (PGY2)

Dr.Lohith (PGY1)

Advice:

Well balanced diet

[05/07, 11:31] +91 92906 89343: Op no: 20210508331

A 47 year old female came to OPD with the c/o Generalised body pains, generalised Tingling sensation since 3 months

Mainly at night

C/o bloating sensation after eating food at night

N/K/C/O HTN,DM,asthma, thyroid disorders, epilepsy, TB.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 78bpm

BP: 100/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr zain (SR)

Dr narsimha (PG2)

Dr lohit (PGY 1)

Daily routine :

Patient occupation - agriculture

daily she wakes up at 4am does house work have breakfast, takes lunch and goes to field by 5 am to work have lunch by 1pm and goes to home by 3pm prepares dinner and have dinner by 8pm and goes to sleep by 9 pm

She reduced her work since 3 months due to her generalised weakness and body pains

Advice :

Proper diet

Avoid spicy and oily food

[05/07, 11:44] +91 93924 39427: Op no. 20230706443

14 year old male came to opd with c/o fever since 4days, intermittent type, mainly during night time, associated with chills and rigor more during night. Relieved on medication

C/O Burning Micturition

N/K/O HTN, DM, Thyroid, seizures disorders

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Febrile

PR: 82bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Zain (SR)

Dr. Narasimha (PGY2)

Dr. Lohith (PGY1)

Daily routine-

Patient occupation - Student

Patient wakes up at 7 am and goes to school at 9 am has lunch at 12 pm, comes back home at 5pm have dinner at 9 pm and goes to sleep at 11pm. Since 4 days he is not able to attend classes due to fever

Advice -

Plenty of oral fluids

[05/07, 12:07] +91 92906 89343: Op no. 20210114745

A 52 year old female came to opd with c/o Tingling sensation in upper limb occasionally

Since 1 month

C/o polyuria, polyphagia, polydypsia

K/C/O type 2 DM since 1 year on

metformin 500mg + glimiptide 1mg PO /OD

K/C/O HTN since 10 years on

Tab Telma H PO/OD

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 78bpm

BP: 100/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr. Zain (SR)

Dr. Narsimha (PGY2)

Dr lohit (PGY1)

Daily routine-

Patient is a housewife wakes up at 4 30 am, preapres lunch box foe her husband by 5 30 and takes rest for sometime. have breakfast at 9 am, do all the house chores , have her lunch at 2 30 pm, have mid day nap and prepares dinner and have dinner by 9 pm and goes to bed by 10pm. Since 1 year she prefers to rest frequently and complete her house chores

Advice -

Strict Diabetic diet

[05/07, 12:50] +91 92906 89343: Op no. 20210114746

29year old male came to opd with the

C/o of chest pain pricking time since today morning 6am, Intermittent for duration of 15 min

H/O similar complaints in the past

H/O regurgitation of food after eating since 10 days

N/K/O HTN, DM, Asthma, Thyroid

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 84bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

RS: BAE +

P/A: soft

Dr. Zain (SR)

Dr. Narsimha (PGY2)

Dr. Lohit (PGY1)

Daily routine:

Patient runs a mobile shop usually wakes up at 7 am have tea and goes to shop by 10 am, have lunch by 2pm or 3 pm depending on his work and have dinner at 10 30 - 11pm and goes to bed at 12 am. Patient do not have proper routine due to his business and has habit of taking alcohol weekly 3 times. Due to his chest pain he feels uneasy and sometimes skips his work and takes rest at home

Advice :

Avoid spicy and oily food

Small frequent food intake

Avoid alcohol

[05/07, 13:50] +91 93924 39427: Op no. 20210123914

54 year old male came to opd with c/o B/l knee joint pain since 1year

C/o cramps in b/l thighs and legs since 10days

C/o difficulty in passing stool since 6day

N/K/O HTN, DM, Thyroid, seizures disorders

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 112bpm

BP: 110/80mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

B/l crepitus present over both knees

Diagnosis? B/l OA knee with constipation

Dr.Zain (SR)

Dr. Narasimha (PGY2)

Dr. Lohith (PGY1)

Daily routine-

Patient occupation - Daily wage labourer

Patient wakes up at 7 am, has breakfast at 8 and goes to work at 10, has lunch at 2pm,comes home at 5pm,has dinner at 10 pm and goes to sleep at 11pm. Patient forces himself to work for their basic needs

Advice -

Advised for admission, but patient is not willing for admission

[05/07, 14:14] +91 92906 89343: OP NO. 20210205285

30 year old female came to the opd with

C/o neck pain since 5 days

C/o body pains since 3 days

C/o Generalised weakness since 4-5 days

Neck pain aggravated with stress / heavy physical activity

K/C/O hypothyroidism since 2 years on medication thyroxine 50 mcg

N/K/C/O HTN, DM, CAD, Thyroid , seizures

On examination:

Patient is conscious, coherent and cooperative.

Neck ROM normal

Temperature: Afebrile

PR: 82bpm

BP: 130/70mmHg

RR: 18cpm

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Diagnosis : Cervical spondylosis

K/c/o hypothyroidism since 2 years

Dr.Zain (SR)

Dr.Narsimha (PGY2)

Dr.lohit (PGY1)

Daily routine:

Patient occupation : agriculture (daily wage labourer)

Patient wakes up at 7 am and goes to work at 9 am has lunch at 2 pm, comes back home at 6pm have dinner at 8:30 pm and goes to sleep at 10pm. She is unable to sleep since 5 days due to pains and force herself to work to earn for their daily needs

Advice :

Cervical collar

Neck Physiotherapy

[05/07, 14:22] +91 93924 39427: Op no. 20230706370

45 year old female came to opd with c/o Abdominal pain in Epigastric region since 15days which aggrevates after eating food.

C/o of indigestion since 15days

H/o regurgitation of food since 15days

N/K/O HTN, DM, Thyroid, seizures disorders

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 68bpm

BP: 90/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Diagnosis? Acid Peptic disease

Dr.Zain (SR)

Dr. Narasimha (PGY2)

Dr. Lohith (PGY1)

Daily routine-

Patient occupation - Agriculture worker

Patient wakes up at 5 am, has breakfast at 7 and goes to work at 8, has lunch at 1pm,comes home at 5pm,has dinner at 10 pm and goes to sleep at 11pm. Patient is unable to sleep due to indigestion and skips dinner sometimes which is affecting her work

Advice -

Avoid spicy and fatty foods

Adequate oral fluids

[05/07, 14:26] +91 93924 39427: Op no. 20230706405

55 year old female came to opd with c/o burning sensation of feet since 10days

Complains of low grade fever, intermittent type, relieved on medication

K/C/O DM type II since 17 years on tab

Glimi 2mg+ Metformin 1000mg PO/BD

N/K/O HTN,Thyroid, seizures disorders

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 71bpm

BP: 100/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Zain (SR)

Dr.Narasimha(PG2)

Dr. Lohith (PG1)

Daily routine-

Patient occupation - Labourer

Patient wakes up at 4 am ,has breakfast at 5am and goes to work at 7am am has lunch at 12 pm, comes back home at 5pm have dinner at 8 pm and goes to sleep at 10pm. Since 10days she is unable to go to work due to burning sensation of feet

Advice -

Advised for admission, Patient said she will come back tomorrow

[05/07, 14:46] +91 92906 89343: OP no. 20230706005

55 year old female came to opd with c/o pain in both lower limbs since 10 months

C/o Tingling sensation in both lower limbs and upper limbs since 10 months

N/H/O HTN,DM,Thyroid,TB, Asthma

examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 74 bpm

BP: 100/70mmHg

CVS: S1 S2+, no murmurs

RS: BAE+ NVBS+

P/A: soft , non tender

CNS-

Reflexes Right. Left

B +2. +2

T. +2. +2

S. +2. +2

K. +2. +2

A. +1. +1

Plantar. Flexor. Flexor

Power -

RIGHT UL 3/5

LEFT U/L 5/5

RIGHT LL 5/5

LEFT LL - 5/5

TONE -

RIGHT UL- N

LEFT U/L -N

RIGHT LL - N

LEFT LL - N

Diagnosis - ? peripheral neuropathy

Dr.Zain (SR)

Dr.Narsimha (PGY2)

Dr. Lohit (PGY1)

Daily routine:

Patient occupation : Agriculture

Patient use to wakes up at 5 am and goes to work by 6 am after having breakfast and has lunch by 12pm and comes back home by 5pm and have dinner by 8 pm and goes to bed by 9pm. Since 10 months due to pains she reduced her working hour and comes back home by 10pm and she is unable to sleep due to pain and Tingling sensation

Advice :

Advised for admission but not willing for admission

[05/07, 15:06] +91 92906 89343: Op no: 20210508331

A 46 year old female came to OPD with the c/o palpitation since 1 month

Aggravated during work and associated with SOB and relieved on taking rest

C/o bloating sensation after eating food at night

K/C/O hypothyroidism since 5 years on medication Tab thyroxine 100 mcg

N/K/C/O HTN,DM,asthma, epilepsy, TB.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 78bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr zain (SR)

Dr narsimha (PG2)

Dr lohit (PGY 1)

Daily routine :

Patient is a daily wage labourer

daily she wakes up at 4am does house work have breakfast, takes lunch and goes to field by 5 am to work have lunch by 1pm and goes to home by 5pm prepares dinner and have dinner by 8pm and goes to sleep by 9 pm

Since 1 month she is unable to work and forcing herself to atleast work for half day to earn for her daily needs. And she is unable to sleep since 1 month.

Advice :

Patient counseling

Adequate rest

[05/07, 15:25] +91 92906 89343: Op no: 20230706493

A 14 year old boy came to OPD with the

C/O fever since 1 day

C/O vomiting since yesterday ( 5 episodes )

C/O headache since yesterday

C/O loose stools since yesterday (4 episodes)

C/o bloating sensation after eating food a

N/K/C/O HTN,DM,asthma, epilepsy, TB, Seizures

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 78bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

No organomegaly

Tenderness present in epigastric region

Dr zain (SR)

Dr narsimha (PG2)

Dr lohit (PGY 1)

Daily routine :

Patient is a student stays in hostel wakes up at 5 am and goes to Stuy hours have break fast by 8 am and attend calses, have tea and Biscuits by 10 30 am and lunch by 1 pm. Completes clases by 5 pm and have snacks have dinner by 8 pm. Patient was unable to attend class today due to fever, vomitings and loose stools

Advice :

Advised for admission but not willing for admission

Plenty or oral fluids

ORS

[05/07, 15:45] +91 93924 39427: Op no. 20230707002

35 year old female came to opd with c/o body pains since 3months, headache since 2months, severe itching on head since 2months, chest pain and tightness since 2months, bloating since 1month

Headache - dragging type, intermittent, more in parietal region, aggravated on work and stress, not relieved on rest.

Severe itching in occipital region associated with rash followed by severe headache

Chest tightness - more after having food

Bloating and belching since 1 month

N/K/O HTN,DM,Thyroid, seizures disorders

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 72bpm

BP: 110/80mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Diagnosis? Stress Headache, Acid peptic disease

Dr.Zain (SR)

Dr.Narasimha(PG2)

Dr. Lohith (PG1)

Daily routine-

Patient occupation -Agricultural Labourer

Patient wakes up at 5 am ,has breakfast at 6am and goes to work at 7am am has lunch at 1 pm, comes back home at 5pm has dinner at 8 pm and goes to sleep at 10pm. Since 2months she doesn't go to work sometimes due to headache

Advice -

Avoid spicy and fatty foods

Adequate hydration

[05/07, 15:46] +91 92906 89343: Op no: 20230706489

A 70 year old male came to OPD with the c/o neck pain since 15 days associated with Tingling sensation in both upper limbs

N/K/C/O HTN,DM,asthma, epilepsy, TB.

On examination:

Patient is conscious, coherent and cooperative.

Temperature: Afebrile

PR: 78bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Diagnosis ? Cervical spondylosis

Dr zain (SR)

Dr narsimha (PG2)

Dr lohit (PGY 1)

Daily routine :

Patient was a farmer

Stopped going for work since 2 years due to Generalized weakness

daily he wakes up at 4 am have breakfast, by 7 am takes lunch by 1pm and takes rest and goes for a walk in the evening and passes his time. Have dinner by 8pm and goes to bed by 9 pm. He is unable to sleep due to neck pain since 15 days

Advice :

Cervical collar

Physiotherapy and neck strengthening exercises

[05/07, 16:07] +91 92906 89343: Op no: 20230706487

A 33 year old female came to OPD with C/O headache and neck pain since 2 months intermittent and diffuse type

Photophobia, phonophobia, nausea present

Aggravated om long journey

H/O trauma to head 2 months ago

C/O pain abdomen since 2 months intermittent type in right Iliac region

Loin to groin pain +

N/K/C/O HTN,DM,asthma, epilepsy, TB Thyroid

On examination:

Patient is conscious, coherent and cooperative.

Head and neck :

Restriction of movement +

Tenderness + on rt side

Abdomen :

Tenderness present in right iliac region and around umbilicus

Temperature: Afebrile

PR: 78bpm

BP: 110/70mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr zain (SR)

Dr narsimha (PG2)

Dr lohit (PGY 1)

Daily routine :

Patient is a daily wage labourer

daily she wakes up at 4am does house work have breakfast, takes lunch and goes to field by 6 am to work have lunch by 1pm and goes to home by 5pm prepares dinner and have dinner by 8pm and goes to sleep by 9 pm

Since 2 month she is unable to work and forcing herself to go to work for her daily needs. During episode of headache she prefers sleeping

Advice :

Patient counseling

Adequate oral fluids

Adequate rest

[05/07, 16:13] +91 93924 39427: Op no. 20230707020

29 year old female came to opd with c/o pain in right chest, groin region, dragging sensation in neck.Aggravated on doing work.Relieved on rest

C/o Sob since 10days which aggrevates on doing work

H/o Burning micturition

N/K/O HTN,DM,Thyroid, seizures disorders

On examination:

Patient is conscious, coherent and cooperative.

No Pallor, cyanosis,clubbing,icterus,

Temperature: Afebrile

PR: 80bpm

BP: 90/60mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr.Zain (SR)

Dr.Narasimha(PG2)

Dr. Lohith (PG1)

Daily routine-

Patient occupation -Agricultural Labourer

Patient wakes up at 5 am ,has breakfast at 6am and goes to work at 7am am has lunch at 1 pm, comes back home at 5pm has dinner at 9 pm and goes to sleep at 10pm. She goes to work despite of her pain for daily wage

Advice -

Advised for admission, but patient is not willing for admission

[05/07, 16:26] +91 92906 89343: Op no: 20230707021

A 18 year old male came to OPD with the

C/O low grade fever since morning 4 am

C/O vomiting ( 6 episodes ) contained food particles

C/O body pains and generalised weakness

N/K/C/O HTN,DM,asthma, epilepsy, TB, Seizures

On examination:

Patient is conscious, coherent and cooperative.

Temperature: 99.6F

PR: 88bpm

BP: 90/50mmHg

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non tender

Dr zain (SR)

Dr narsimha (PG2)

Dr lohit (PGY 1)

Daily routine :

Patient is a student stays in hostel wakes up at 6 am have breakfast and goes to clg by 8 am and attend calses, have lunch by 1 pm. Completes clases by 5 pm and have dinner by 8 pm. Patient was unable to attend class today due to fever snd vomitings

Advice :

Plenty of oral fluids

ORS

[05/07, 16:38] +91 93924 39427: Op no: 20230707469

A 40 year old male came with

C/o inability to recover from Lt. Hemiplegia

K/c/o Lt. Hemiplegia 4months back and on Medication - Tab. ECOSPRIN 150mg, Tab. CLOPIDOGREL 78mg, Tab. ATORVAS 10mg,

K/c/o HTN since 1 year and on medication Tab. CINOD-T 10/40mg PO/ OD

N/K/C/O Asthma, epilepsy, Thyroid disorders, TB, CVA, CAD.

General examination:

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis,clubbing, lymphadenopathy , edema

Vitals-

Temperature: Afebrile

PR: 72bpm

BP: 110/90 mmHg

Systemic examination:

CNS-

Reflexes Right. Left

B +2. +3

T. +2. +3

S. +2. +3

K. +2. +3

A. +2. +2

Plantar. Flexor. Flexor

Power -

RIGHT UL 5/5

LEFT U/L 4/5

RIGHT LL 5/5

LEFT LL - 4/5

TONE -

RIGHT UL- N

LEFT U/L -N

RIGHT LL - N

LEFT LL - N

CVS: S1 S2+, no murmurs

RS: BAE+ NVBS+

P/A: soft , non-tender

Daily routine: Patient stays at home since 4months, wakes up at 8am, has breakfast at 9am, lunch at 1pm, dinner at 10pm

Advice:

Advised for physiotherapy

[05/07, 16:41] Dr. Rakesh biswas: This daily routine is when?

What was it hourly 4 months back and how did it change after he developed the illness?

[05/07, 16:44] +91 93924 39427: Sorry Sir forgot to mention he was a mechanic 4months back he used to go to work at 10 am and come back by 6pm

[05/07, 16:45] Dr. Rakesh biswas: What work did he do as a mechanic?

[05/07, 16:46] +91 93924 39427: He was a car mechanic Sir

[05/07, 16:48] Dr. Rakesh biswas: What exactly did he do from 10AM to 6PM?

[05/07, 16:49] Dr. Rakesh biswas: How much disability does he have now? What is preventing him from doing his earlier work?

[05/07, 16:53] +91 93924 39427: Sir he usually changes tires and does some repair work, since 4months because of his Lt. Hemiplegia he says he's not able to lift/use his leftarm even for his daily works which affected his work

6th July 2023

[06/07, 08:32] Dr. Rakesh biswas: [05/07, 08:32] Dr Surender Mittal

MD (Medicine ) and Diabetologist

Practising in Haryana: A young female 12yr having weight 52kg

RBS 389

HbA1C 13.3

C peptide 3.09

Urine ketone negative

H/o weight loss /vaginal infection

Father is diabetic/Mother is Prediabetic

GAD 65 negative

Started on Basal Bolus initially but after 1 month shifted to glimiperide 2mg and Lantus after the discussion in the CME group in September with diagnosis of MODY

Now she is on glimiperide 0.5mg and her FBS 123/Pp 156

HbA1C 5.7

This is the genetic testing report

Kindly guide what it signifies ?

[05/07, 08:33] Dr Surender Mittal

MD (Medicine ) and Diabetologist

Practising in Haryana: Kindly guide sir what it is wether Mody or something else and how to approach further👇

[06/07, 10:22] Lalith: Op no : 20230707965

A 60 y / Male patient who is a k/c/o DM type 2 came to opd for regular checkup and c/o polyuria and polydipsia.

No H/O weight loss

No h/o tingling and numbness in B/L feet

No h/o fever,burning micturation

On Tab metformin 500 mg

Telma -AM 40 /5 ( k/c/o htn since 5 yrs )

o/e : pt c/c/c

Afebrile

Pr:82

BP:130 /80 mmhg

RR : 18

Cvs : s1 s2 + no murmurs.

Rs : BAE + NVBS +

Dr Nikitha (SR)

Dr Keerthi (pg y2 )

Dr Ajay (pgy1).

Daily routine :

Patient occupation : Farmer .

Patient was apparently asymptomatic 2 months back and was working 8 hours a day from 9 am to 5 pm after waking up at 5 30 am and sleeps around 8 at night after having dinner at 7 after which he was incidentally detected with diabetes when he visited a hospital with c/o dizziness and swollen legs .

The recent diagnosis with diabetes type 2 did not have any effect on his life style other than his food habits like completely restricting sugar intake .

Advice :

Strict diabetic diet .

[06/07, 11:15] Viharika: Op no- 20230707957

A 70yr old male came with the C/o pain abdomen since 1 week in epigastric region , burning type of pain and C/o Bilateral upper and lower limb pain since 5 days

H/o belching present

No h/o nausea, vomitings, fever.

K/c/o HTN since 10 years and on medication Tab.TELMA 40 MG

O/E - pt is c/c/c

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

Afebrile

PR- 70bpm

BP- 130/80mmHg

Systemic examination-

CVS- S1,S2 + ; No murmurs

RS- BAE + NVBS+

Daily routine-

Occupation- Farmer

Patient wakes up at 5am , drinks tea and does farming and will have breakfast at 9.30 am, lunch at 1pm and continue farming and dinner at 8 pm .Goes to sleep at 9pm.

Advice- Dietary restriction

[06/07, 12:05] Lalith: Op no : 20230708804

A 22 year old patient came to op with c/o headache since 4 days insidious in onset ,continuous with nausea ,vomitings ,photo phobia, phonophobia and giddiness during the episode .

Vision normal .

C/O b/l upper and lower limbs tingling sensation since 4 days and low grade fever only during the episode .

Diagnosis: ? Migraine.

Occupation : home maker .

Daily routine :

Patient was apparently asymptomatic 4 days back and minding her routine work of taking care of the house which involves moderate physical work after she wakes up at 7 am with sound sleep of 8 hours after which she experienced severe headache starting from forehead that gradually spread to the base of her head that was associated with discomfort to white light and vomitings with sensation of loss of balance and all these symptoms used to go away after two hours and would start again making it difficult and sometimes unable to take care of daily activities.

Advice :

Patient was asked to admit but not willing .

[06/07, 12:57] Viharika: Op no- 20230523356

A 52yr old female came with C/o multiple joint pains since 1year

B/L Elbows, knees, shoulders, HCP , ankle, wrist.

Morning stiffness present relieved with movement.

Swelling - ; Tenderness -

Patient was apparently asymptomatic 2 years back then she developed multiple joint pains and were relieved on medication.

Presently since 1year she having c/o multiple joint pains.

O/E

pt is c/c/c

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

Afebrile

PR- 90bpm

BP- 120/90mmHg

Systemic examination-

CVS- S1,S2 + ; No murmurs

RS- BAE + NVBS+

Daily routine-

Patient stays at home wakes up at 6am , breakfast at 9.30 am, lunch at 1pm and dinner at 8 pm .Goes to sleep at 10pm.

[06/07, 12:57] Viharika: Op no- 20230708330

A 42 yr old female came with C/o occassional burning micturation

No h/o Increased frequency

No h/o fever, cough, vomiting, shortness of breath, chest pain.

No h/o menstrual irregularity, hairloss

O/E-

pt is c/c/c

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

Afebrile

PR- 74bpm

BP- 110/70mmHg

Systemic examination-

CVS- S1,S2 + ; No murmurs

RS- BAE + NVBS+

Daily routine-

Occupation- Tailor

Patient wakes up at 5.30am goes to walk for 30 mins and will have breakfast at 9am and does tailoring work till lunch, lunch at 1pm and dinner at 8 pm .Goes to sleep at 10pm.

[06/07, 13:28] Lalith: Op no : 20230709358.

A 70 year male patient came to op with c/o chest pain since morning left sided, dragging type and not radiating

H/O more pain after eating food , SOB grade ll and excessive sweating .

H/O spicy food intake .

K/C/O DM since 12 years and on medication with T.Metformin 500 mg

O/E - pt is c/c/c

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

Afebrile

PR- 72bpm

BP- 12/80mmHg

Systemic examination-

CVS- S1,S2 + ; No murmurs

RS- BAE + NVBS+

Diagnosis : GERD

Daily routine :

Occupation : Farm worker

Patient was apparently asymptomatic 1 month back and was busy in his daily routine of gardening for 8 hours that involves strenuous physical work balanced by a sound sleep of 8 hours after which he was experienced chest pain a/w sob and increased pain after having food and aggravated after some time and was doing fine all along until this morning with similar complaints.

[06/07, 14:52] Viharika: A 25yr old female came with C/o pain in epigastric region since 1month.

C/o tingling sensation in palms since 2days.

Burning type of pain +

Palpitations +

No h/o nausea, vomitings, shortness of breath, sweating.

O/E

pt is c/c/c

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

Afebrile

PR- 80bpm

BP- 110/70mmHg

Systemic examination-

CVS- S1,S2 + ; No murmurs

RS- BAE + NVBS+

Diagnosis- Acute gastritis

Daily routine-

Patient stays at home wakes up at 7am , breakfast at 9 am, lunch at 1pm and dinner at 8 pm .Goes to sleep at 11pm.

Advise- Restrict spicy food

[06/07, 16:27] Lalith: Op no : 20230709513

A 75 year male patient came to the op with c/o b/l Pedal edema since 1 week ,pitting edema extending upto knee joint .

Tingling and numbness in left lower limb

Sob since 4 days grade ll to grade lll and h/of occassional chest pain

K/c/o htn and is on metoprolol and dytor plus .

O/E - pt is c/c/c

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

Afebrile

PR- 82bpm

BP- 140/80mmHg

Systemic examination-

CVS- S1,S2 + ; No murmurs

RS- BAE + NVBS+

Occupation :wage worker

Patient was apparently asymptomatic 1 week back when he was doing doing his daily routine of hard labour and had sob which he ignored and went to sleep that night with some difficulty in breathing which was relieved after changing his sleeping position in bed.next morning he noticed swelling in lower extremities oh his legs that gradually progressed till the knees and made breathing difficult than before which made him visit the hospital .

Advice : Patient not willing to admit .

[06/07, 16:43] Lalith: Op no: 2023064751

A 52 yr male came to OPD with c/o burning micturition since 1 month

K/c/o dmtype 2 and is on medication with metformin 500 mg .

On examination:

Patient is conscious, coherent, cooperative

Temp: afebrile

Pr: 70bpm

Bp: 120/70 mm Hg

Cvs: S1 S2 heard,No murmurs

Rs: bae+, NVBS heard

P/a: soft, non tender

Dr NIKITHA (SR)

Dr KEERTHI ( Pgy2)

Dr AJAY ( Pgy1)

Daily routine:

Occupation: wage worker

Patient wakes up at 6 am and gets ready by 8 am and has breakfast at 9 am . Goes for work and have lunch at 2 pm .comes home at 5 pm and sleeps at 9 pm.

7th July 2023

[07/07, 09:52] Prashant: 20330702621

52 yrs old male patient came to OPD with

C/o B/L big toe and second toe pain since 10 days

Pt was apparently asymptomatic 10 days back , then he developed left big toe pain which was sudden in onset, gradually progressive . 6 days back he also developed right big toe and second toe pain ,of pricking type .

Occasional alcoholic

Gives history of drinking carbonated drink for the last one month

Works in electrical department

K/c/o HTN since 5 yrs and on medication Telmisartan 40 mg

Not a k/c/o DM , asthma , thyroid , epilepsy

CAD, CVA

Diagnosis

Gouty arthritis

Advise

Abstain from alcohol

Avoid red meat

[07/07, 09:59] +91 98486 60281: Op no:20210317742

A 34 years male patient came to op with c/o tingling and numbness of both lower limbs with polyphagia and polydipsia.

K/C/O Type 2 Diabetes mellitus since 5 years and on medication T.Metformin 500mg morning and evening

T.Glimiperide 1mg once daily

O/E-pt is c/c/c

No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,edema.

Afebrile

PR-80bpm

BP-130/80mmhg

Systemic examination -

CVS-S1,S2+ ;No murmurs

RS-BAE + NVBS +

Daily routine:

Occupation:works in automobile showroom

Patient wakes up at 7:30am,have breakfast at 8:30am and goes to work.He ll have lunch at 1:30 to 3pm based on his work,goes to home at 7pm,have dinner at 8pm and goes to sleep at 11pm.

Advice:

Strict diabetic diet

Regular exercise

[07/07, 10:14] Dr. Rakesh biswas: Duration of symptoms?

What work does he do?

What happened to his routine after he developed the symptoms?

[07/07, 10:22] Prashant: 20230710269

13 yr old boy came to OPD with c/o fever for 1 month and low back ache for 1 month

Insidious in onset, evening rise of temperature associated with sweating, associated with chills and rigors during the spike of temperature

C/o decreased weight and appetite

No c/o cough or cold

No c/o burning micturition , suprapubic pain ,hematuria or black colored urine

No c/o headache , neck stiffness

Low backache was insidious in onset , non radiating

General examination

Patient is Conscious, coherent and Cooperative

Pallor present

Clubbing

Icterus

Edema

B/L inguinal lymphadenopathy present (both vertical and horizontal group)

Vitals

BP 90/60 mm Hg

PR 90 bpm

Temperature 100.1 F

CVS S1 , S2 present, no murmers

CNS NFND

RS BAE, NCBS

PER ABDOMEN SOFT AND NON TENDER

ADVISE FOR ADMISSION

[07/07, 10:29] +91 98486 60281: Duration:6 months

He interacts with clients and gives vehicle information sir

His daily routine is not affected

[07/07, 11:07] +91 98486 60281: OP:20230710270

A 68 years me patient came to op with c/o cough with sputum since one month whitish in colour.

No sweating,chills,rigors,headache,burning micturition.

O/E-pt is c/c/c

No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy

Afebrile

PR:80bpm

BP:100/60mmhg

Systemic examination -

CVS-S1,S2 +,no murmurs

RS-BAE+ NVBS+

Occupation:He stays at home.Wake up at 6am,Eats food at 9am ,reads newspaper and takes some rest

,have dinner at 7pm and sleeps at 8pm

Advise:

Avoid cold foods

[07/07, 11:29] +91 98486 60281: OP:20230707972

A 28 years male came to opd with c/o generalized weakness since 2 months,frequency of stools -6 to 7 episodes/day,normal in consistency, immediately after eating food.

Weight loss(6-8kg in 6 months)

Giddiness on waking up from bed

Aggravated with position change

H/o TB 12 years ago and used medication for 2 years

H/o Seizures 10 years ago used medication

N/H/O fever,cough,SOB,Vomiting,abdominal pain

O/E-pt is c/c/c

No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy

Afebrile

PR-86bpm

Supine-100/60

Standing-90/60

Systemic examination:

CVS:S1,S2 +,No murmurs

RS:BAE+ NVBS+

CNS:NAD

P/A:Soft,no tenderness

Advise:

Avoid spicy food

Small frequent meals

[07/07, 11:42] Prashant: 20230524511

50 yrs old female came to OPD with c/o SOB of grade 2 since 2 months

Insidious in onset, aggravated on doing lifting heavy weights

Associated with palpitations

Easy fatiguability

No giddiness

No h/o pedal edema

No chest pain , heaviness of chest

No h/o decreased urine output or burning micturition

No fever , headache, cough

Home maker by occupation

K/c/o DM Type 2 for 7 yrs and on medication

Not a k/c/o HTN, asthma, epilepsy, CAD , CVA, TB

Good appetite

No weight loss

Takes mixed diet

Sleep adequate

No addictions

General Examination

Pt is C/C/C

Pallor present

Cyanosis absent

Icterus absent

Edema absent

Generalised lymphadenopathy absent

Vitals

Afebrile

BP 160/ 80 mm Hg

PR 110 bpm

Systemic examination

CVS. S1 S2 present

CNS NFND

RS BAE , NVBS

Per abdomen Soft , Non tender

[07/07, 12:00] +91 98486 60281: OP:20230710270

A 56 years old female came to opd with c/o headache,neck pain,nausea,easy fatiguability and generalized weakness since 6 months

N/K/C/O Hypertension ,

Diabetes

O/E-pt is c/c/c

No signs of pallor,icterus,clubbing, cyanosis,lymphadenopathy

Afebrile

PR:60bpm

BP:100/60mmg

Systemic examination:

CVS-S1,S2+,no murmurs

RS-BAE+ NVBS+

CNS-NAD

P/A-soft ,no tenderness

Occupation: Daily wage labourer

Since since months she stopped going to work due to easy fatiguability.

[07/07, 14:36] +91 6309 842 248: Op :20230711328

A 55 years old patient came to opd with

C/o-

1)Burning sensation in epigastric region since 15days

Past history-

Not a k/c/o DM,HTN, thyroid abnormalities, asthma,TB,and epilepsy

On examination

Patient is conscious,coherent and cooperative

Temp- afebrile

PR-109BPM

Bp- 130/70

RR-16cpm

Cvs-S1,S2 heard, no murmurs

Resp- BAE+ , NVBS heard

P/A- soft , nontender

Advice-

Avoid spicy food

Daily routine-

She is a housewife .

She wakes up at 5 am and does her daily chores and eats breakfast at 9 o clock and plays with her grandkids and then prepeare for lunch and eats at around 12:30 and then takes a nap then wakes up in the evening at 5:30 pmand have snacks (tea and biscuits) then she prepares for dinner at 7:30pm and eats at 8:30pm and then goes to bed at 9:30pm.

Dr. Harika pg y1

Dr. Pavani pg2

Dr. Sushmitha sr

[07/07, 14:38] Dr. Rakesh biswas: This routine is before 15 days? What happened to the routine once her symptoms started?

[07/07, 14:39] +91 6309 842 248: Her routine has not changed even after the symptoms sir

[07/07, 15:18] +91 6309 842 248: Op: 20210421329

A 39 years old patient came to opd with

C/o- palpitations since 1years

Past history-

Known case of hyperthyroid since 6 years on medication- carbimazole 5mg

Not a known case of DM, asthma, TB and epilepsy

On examination

Patient is conscious, coherent and cooperative

Temp -afebrile

PR- 74BPM

RR-18cpm

Bp- 160/110mmhg

Cvs -S1,S2 heard, no murmurs

Resp -BAE+, NVBS heard

P/A- soft , nontender

Advice -

Continue medication

Daily routine :

Occupation- band member for functions and also a tailor

He wakes up at 6 o clock and does his daily activities and freshes up and goes to tailor shop and does his work and goes home at 1 o clock and eats lunch and sits/ sleeps for some time and goes to work either band work or tailor work and at 10 o clock he goes to home and eats dinner and then he sleeps at 11 o clock

And his daily routine is not affected after the symptoms also

[07/07, 15:29] Sreelekha ❤: Op no -20230710280

A 22 year old female patient came to OPD with the complains of easy fatiguability and generalized weakness since 2 months.

C/o SOB since 2 months grade 2

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

On Examination-

Pt is conscious, coherent and cooperative.

Pallor present

No signs Icterus, cyanosis, clubbing, lymphadenopathy.

VITALS

Temperature -Afebrile

Pr: 66 bpm

Bp: 110/80 mm Hg

SYSTEMIC EXAMINATION

Cvs: S1 S2 heard.

Rs: bae+, NVBS heard

P/a: soft, non tender.

CNS: NFND

Daily routine:

Patient is a college student. She wakes up daily at 7am and goes to college at 8am. She attends her classes and come back at 6pm and helps in household work. Eats dinner at 9pm and sleeps at 11pm.

Since 2 months the patient's routine has not changed but she finds it difficult to do everyday work.

Advice:

The patient was adviced for admission for further evaluation of anemia but she was not willing.

Patient is adviced to take iron rich food and a well balanced diet

Dr. Sushmitha SR

Dr. Pavani pgy2

Dr. Harika pgy1

[07/07, 15:48] +91 6309 842 248: Op-20230711343

A 36 year old female patient came to opd with

C/o-

1)general weakness since 1 week

2) easy fatiguability since 1 week

Past history-

Not a known case of asthma , TB,DM,epilepsy,and thyroid abnormalities

On examination-

Patient is conscious, coherent and cooperative

Temp - afebrile

PR- 76BPM

Bp- 120/80mmhg

RR- 16cpm

Cvs -S1,S2 heard , no murmurs

Resp- BAE+, NVBS heard

P/A- soft and non tender

Advice -

Take iron rich food and balanced diet

Avoid tea and consume milk

Patient is advised for admission for further evaluation for anemia

Daily routine :

Occupation- principal

She starts her day at 6 o clock in the morning and does her daily activities and prepared for breakfast and have her breakfast at 8:30 and goes to school at 9 o clock and at 12:30 she eats her lunch and at 4 o clock she comes home and have snacks (tea or coffee)and at 7 o clock she prepared dinner for her family and eats at 8 o clock and the she sits and watches television and goes to bed at 9 o clock

After the symptoms has occurred -

Not going to work properly and takes rest at home

[07/07, 16:01] Sreelekha ❤: Op no. 20210217599

A 28 year old male came to the opd with the complains of fever since yesterday. Releived on taking medication.

C/o cold since 2 day.

C/o cough associated with sputum, mucoid in consistency since 2 day.

Not associated with fever, headache, loose stools, vomitings.

N/K/C/O HTN, DM, asthma, thyroid disorders, epilepsy, TB, CVA, CAD.

On examination:

Patient is concious, coherent and cooperative.

VITALS

Temperature: Afebrile

PR: 80 bpm

BP: 120/70 mmHg

SYSTEMIC EXAMINATION :

CVS: S1 S2+, no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft , non-tender

DAILY ROUTINE:

The patient is a farmer . He wakes up at 5am gets freshened up and goes to his farm. He has lunch at 12:00pm. he come back home by 4:00pm. He has dinner at 9:00pm and sleeps at 10pm.

The patient's routine has not been changes due to his symptoms but he feels very tired to continue his daily routine and hence came to us.

Advice:

Adequate hydration and proper rest

Symptomatic treatment

Dr. Sushmitha SR

Dr. Pavani pgy2

Dr. Harika pgy1