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
Rx
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
Rx
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, 11:32] 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
Pt
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)
Rx
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
Rx
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
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
[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
Bp
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 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, 14:51] 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:
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 affected couldn't perform her 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
BP
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
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