PLA BOOK PROJECT DRAFT OPD week 1(11 August-12th August)
Week-1
11 August 2023,Friday
[8/11, 10:41] +91 79819 60542: 1. OP no -20230817212
49year old man a K/C/O of graves ophthalmopathy since 3 months came to the OPD with chief complains of watering of eyes since 2 days.
There were no aggravating or relieving factors.
Not a k/c/o -HTN,CAD,CVA, asthma, epilepsy
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 70 bpm
Bp: 110/80 mm Hg
Rr: 18 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no added sounds
Rs:-BAE+, NVBS +
P/a: - soft, non tender
CNS: - NFD
Daily routine-
Patient is a paddy field farmer, he wakes up by 5:30 in the morning, drinks tea, helps his wife with household work (cleaning house) and goes to work by 8:00 am.
He does farming till 12-12:30 pm and has lunch. He rests for 45mins - 1 hour and again gets back to work. He will reach home by 5:00pm and watches television and goes for a walk with his friends till 8:00pm, comes back and has dinner and sleeps by 10:00pm
The above mentioned complains haven’t effected his daily routine yet.
[8/11, 10:51] Nikhileshwar KIMS: Op no. 20210324570
A 57yr old female came to OPD with C/o bilateral knee pains since 6 years, insidious in onset, non progressive, dragging type of pain, radiating from knee to hip
No H/o chest pain, SOB, palpitations, orthopnea, sweating
No H/o weight gain or loss
No H/o burning micturition, constipation, vomiting, nausea
K/c/o HTN since 10 years and is on telma 40 mg
N/k/c/o ,DM, epilepsy, thyroid disorders, CAD,CVD, asthma.
On Examination-
Patient is conscious, coherent, cooperative
Temp: afebrile
Pr: 78 bpm
Bp: 130/70mm Hg
Rr: 20 cpm
No signs of pallor , icterus, cyanosis,clubbing and lymphadenopathy.
CVS: S1 S2 heard, No murmurs
RS: bae+, NVBS heard
P/A: soft, non tender, bowels sounds+
CNS - NFND
Daily routine-
The patient is a homemaker. She wakes up at 4:00 am, freshens up, nd has her breakfast at 6:30am and does her household work by 10:00 am. After that she watches tv for sometime. She has her lunch at 1 pm and sleeps after lunch till 4:00 pm. She has his dinner by 7:00 pm. She goes to bed by 8:00 pm. Her daily activities don't get disturbed because of the complaints.
[8/11, 11:05] +91 79819 60542: OP no - 20230817671
47years woman came to the OPD with chief complains of burning micturition since 2-3 years with polyuria on gynecology consultation.
C/O belching and regurgitation associated with lower abdominal pain.
Not a k/c/o -HTN,CAD,CVA, thyroid problems, asthma, epilepsy
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 79 bpm
Bp: 120/80 mm Hg
Rr: 16 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no added sounds
Rs:-BAE+, NVBS +
P/a: - soft, non tender
CNS: - NFD
Daily routine-
Patient is a textile factory worker. Her job is to cut fabrics and has to deal with standing for long hours.
She wakes up by 5:30- 6:00 am and does household work till 8:00 and has breakfast.
She starts working by 9:00 am and has her lunch by 12:30pm. She takes rest for 30min talking to her fellow workers and gets back to work by 1:30 - 2:00 am.
He works till 6:00pm and goes back to home and cooks dinner for her family.
She has her dinner by 9:00 and goes to sleep by 10pm.
The above mentioned complaints have effected her daily routine yet.
[8/11, 11:46] +91 79819 60542: OP no - 20230818233
32years woman came to OPD with chief complaints of chest heaviness accompanied with shortness of breath since 3 days.
Belching +, regurgitation +, Flatus +
C/o productive cough associated with headache.
C/o sweating, palpitations
No c/o orthopnea, PND
No c/o loose stools, nausea, vomiting
No c/o burning micturition
No c/o fever
K/C/O migraine since childhood
Not a K/C/O HTN/ thyroid disorders/ DM/ CAD/ CVA
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 82 bpm
Bp: 130/80 mm Hg
Rr: 19 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Rs- left SSAISA mammary crepts +, wheeze +
Cvs:-S1 S2 heard, no added sounds
P/a: - soft, non tender
CNS: - NFD
Daily routine-
Patient is a house wife, she wakes up by 6 in the morning does all the household chores, sends her 2 children for school and has her breakfast by 10:30, she has her lunch by 1:30pm and after that she watches television and takes a nap for 40-45 minutes after that does cooking and has her dinner by 8 pm and goes to bed by 10pm.
The above mentioned complains have effected her daily routine.
[8/11, 12:03] Nikhileshwar KIMS: Op no. 20230818181
A 59yr old female came to OPD with C/o fever since 3 months, diagnosed as typhoid outside, loss of appetite, belching and regurgitation present, B/L lower limb dragging type of pain, generalised weakness present
Occasional c/o midsternal pain, resolves automatically.
No C/o loose stools, vomiting, nausea
No H/o cold, cough
No H/o burning micturition,
K/c/o DM Type 2 since 10 years and is on gliclazide 30 mg and metformin 500 mg
N/k/c/o , HTN, epilepsy, thyroid disorders, CAD,CVD, asthma.
On Examination-
Patient is conscious, coherent, cooperative
Temp: afebrile
Pr: 89 bpm
Bp: 110/70mm Hg
Rr: 24 cpm
No signs of pallor , icterus, cyanosis,clubbing and lymphadenopathy.
CVS: S1 S2 heard, No murmurs
RS: bae+, NVBS heard
P/A: soft, non tender, bowels sounds+
CNS - NFND
Daily routine-
The patient is a homemaker. She wakes up at 5:30 am, freshens up, nd does her household work by 8:00 and after that she has her breakfast at 8:30am. After that she watches tv amd spends time with family. She has her lunch at 2 pm and sleeps till 5:00 pm. If there's any requirement regarding groceries she goes to marketplace after 5 and has her dinner by 8:00 pm. She goes to bed by 9:00 pm. Her daily activities don't get disturbed because of the complaints.
[8/11, 12:41] Nikhileshwar KIMS: OP no - 20230818261
21 years female came to the OPD with chief complains lower back pain since 1 week
Lower back pain was insidious in onset, continuous, progressive; accompanied with B/L LL dragging type of pain.
C/o tingling sensation, aggravated on prolonged posture, no relieving factor present.
No c/o burning micturition
No c/o loose stools, nausea, vomiting
Not a k/c/o -HTN, DM, CAD, CVA, thyroid problems, asthma, epilepsy
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 69 bpm
Bp: 120/80 mm Hg
Rr: 16 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no added sounds
Rs:-BAE+, NVBS +
P/a: - soft, non tender
CNS: - NFD
Daily routine-
Patient is a BDS student currently studying in KIMS narketpally.
She wakes up at 6:00 in the morning, uses mobile for a while and freshens up by 7:30 and has breakfast before leaving for college at 8:00am. Attends classes till 1pm and has her lunch by 1pm.
She has snacks in the evening around 5pm and goes back to home and does her academic works after that
She has her dinner by 9:00 pm and goes to sleep by 10:00 pm.
The above mentioned complains have not effected her daily routine yet.
[8/11, 15:01] +91 91210 54152: OP number: 20230818773
A 44 year old male came to opd with complaints of abdominal Bloating sensation since 1 year, aggravated after having food.
C/o constipation occasionally
Giddiness+
No c/o Belching, regurgitation
No c/o Chest pain, SOB, Orthopnea, PND, sweating,Palpitations.
No c/o Cough, cold, fever.
No c/o burning micturition
H/o Anal fissure surgery 1 year ago
K/c/o HTN since 2 years on TELMA-AM PO/OD
N/k/c/o DM ,Asthma, TB ,Epilepsy, CVD, CAD, Thyroid disorder.
ON EXAMINATION:
Patient is conscious,coherent,cooperative
No Pallor, icterus, cyanosis, clubbing, lymphadenopathy
Temperature: Afebrile
PR:80bpm
BP:110/70mmhg
RR: 14cpm
CVS: S1 S2+,no murmurs
CNS: NFND
RS: BAE+ NVBS+
P/A: soft,non tender
DAILY ROUTINE:
Occupation: Teacher
Patient wakes up at 5am , freshens up and walks for about 30min. He has his breakfast by 7am. Then he spends sometime reading the newspaper and goes to the school. He teaches maths and English for 7th grade. He has about 5-6 classes per day , each class lasting for 45min-1hr. He is mostly standing during the day(while teaching). He has lunch at 1pm along with the other school staff. He goes home after 4, has his evening coffee after going home. When asked he told that he is under a lot of stress due to family issues. He has dinner by 8pm and goes to sleep by 9:30-10pm. The above mentioned complaints haven’t disturbed his daily routine yet.
12 August 2023,Saturday
[8/12, 10:36] +91 96760 48138: Op mly: 2023819058
A42 year old female came with the c/o of chest pain on the left side non radiating, aggravated on taking spicy food,c/o of occasional palpitations,
No c/o of sob ,pnd, orthopnea
Not a k/c/o DM ,CAD,CVA,seizures,HTN ,TB,Asthma
On Examination-
Patient is conscious, coherent, cooperative
Temp: afebrile
Pr: 82 bpm
Bp: 120/70 mm Hg
Rr - 22cpm
Mild pallor
No signs of , icterus, cyanosis,clubbing and lymphadenopathy.
Cvs: S1 S2 heard,No murmurs
Rs: bae+, NVBS heard
P/a: soft, non tender, bowels sounds+
CNS - NFAD
Daily routine- pateint is home maker
Patient wakes up at 7 and freshens up and does her household chores and sends her children to school and has her breakfast by 9 am . Then spends her time by taking rest or helping in household chores , 1 pm she has herlunch , then takes nap till 5 pm , then by 8:30 pm eats her dinner and goes to sleep by 9:00 pm .
Her daily routine is not affected by the above mentioned complains
[8/12, 10:36] +91 96760 48138: Op no: 20230819461
A 40 year old female came with the cheif complains of fever since 2 days associated with chills and rigor ,no loose stools and vomitings,no h/o of cough amd cold
C/o retroorbital pain ,c/o of generalized weakness and chest pain on and off, c/o of sob grade one mmrc, no aggravating and relieving factors,
Not a k/c/o DM ,CAD,CVA,seizures,HTN ,TB,Asthma
On Examination-
Patient is conscious, coherent, cooperative
Temp: 99.7 f
Pr: 82 bpm
Bp: 100/70 mm Hg
Rr - 22cpm
Mild pallor
No signs of , icterus, cyanosis,clubbing and lymphadenopathy.
Cvs: S1 S2 heard,No murmurs
Rs: bae+, NVBS heard
P/a: soft, non tender, bowels sounds+
CNS - NFAD
Daily routine- pateint is home maker
Patient wakes up at 7 and freshens up and does her household chores and has her breakfast by 8 am mostly eats idilli /dosa . Then spends her time by taking rest or helping in household chores , 1 pm she has herlunch , then takes nap till 5 pm after waking up she drinks his tea and then spends her time talking with her neighbours , then by 8:30 pm eats her dinner and goes to sleep by 9:00 pm .
Her daily routine is not affected by the above mentioned complains
Advice:
Patient managed conservatively with medication and adviced adequate hydration
[8/12, 11:10] +91 96760 48138: Op no: 20210111742
A 25 year old female came with the cheif complains of pain in both lower limbs since 2 days, dark coloured patch on left leg since 2 days, fever since 2 days, generalised body pains since 2 days, no h/o of fever, vomitings, watering of eyes, burning micturition, photophobia
Not a k/C/o-DM ,CAD,CVA,seizures,HTN ,TB,Asthma
On Examination-
Patient is conscious, coherent, cooperative
Temp: febrile
Pr: 82 bpm
Bp: 120/80 mm Hg
Rr - 22cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy.
Cvs: S1 S2 heard,No murmurs
Rs: bae+, NVBS heard
P/a: soft, non tender, bowels sounds+
CNS - NFAD
Daily routine:
She is house wife she is preparing for group one
She wakes up early in the morning and studies for one hour and does her household works amd has ger Breakfast at 9 am and has her lunch at one pm and studies later and has her dinner at 9pm sleeps at 10 pm
Her daily routine is not affected by the above mentioned complains
Advice:
Pt was advised symptomatic treatment
Adequate rest and hydration
[8/12, 11:54] +91 96760 48138: Op number - 20230820065
32 year old female came with complaints of headache which is diffuse type since 5 days
Headache is diffuse type more during the morning and night , no c/o of nausea , vomitings photophobia, photophobia giddiness , headache relieved on medication
Not k/c/o Dm, Htn, epilepsy, asthma, CVD, CVA
On examination
Pt is c/c/c
PR - 84bpm
RR - 14cpm
Bp - 110/70mmHg
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy
Cvs - S1S2 +, no murmurs
RS - BAE+, NVBS
Cns - NFND
Per abdomen -soft and non tender
Advice
Symptomatic treatment
Daily routine
She is home maker, she wakes up around 5am and checks her smartphone upto 6am then she prepares breakfast for her children and make them ready for school and send them to school by 9clock. She does her household works from 9 to 11 am and cooks for lunch by 12pm.then she goes to school to give lunch box to their children and then she returns home by 1pm. She has her lunch at 1 30pm andshe spends watching television in the afternoon upto 4pm and in the evening she picks her kids from school at 5pm and makes snacks ready for the kids by 6pm, she helps her kids finish their homework by 8pm.then prepares for dinner and has dinner by 9 30 and sleep by 11pm
[8/12, 12:38] +91 96760 48138: Op no 20230820092
A 35 year old came with the C/o of pain abdomen since 3 days
No c/o of fever, cough cold, palpitations orthopenea, pnd , vomitings and loose stools, burning micurition
O/E pt is c/c/c
Afebrile
PR - 94bpm
RR - 17cpm
Bp - 120/70mmHg
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy
Cvs - S1S2 +, no murmurs
RS - BAE+, NVBS
Cns - NFND
Per abdomen -soft and tender in the lower qudrants of abdomen
Advice
Symptomatic treatment
And adequate hydration
Daily routine
She helps her husband in farming in paddy feilds
Wakes up early in the morning does her household work and has breakfast at 9am and goes to paddy feilds has her lunch at one and cones back to home and takes rest and prepares dinner , has dinner at 9pm and sleeps at 10pm
Her daily routine is not affected by above mentioned complaints
[8/12, 14:15] +91 96760 48138: Ip no: 20230820176
A 35 year old male came with
C/o of lower back ache radiating to lower limbs since 6 months
C/o of pain in the right hypochondrium, generalized weakness
No c/o of orthopnea, pnd, sob
No c/o of chestapain palpitations
O/E pt is c/c/c
Afebrile
PR - 78bpm
RR - 18cpm
Bp - 130/70mmHg
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy
Cvs - S1S2 +, no murmurs
RS - BAE+, NVBS
Cns - NFND
Per abdomen -soft and non tender
Advice
Symptomatic treatment
And adequate hydration
Daily routine-
He is farming
Patient is a paddy field farmer, he wakes up by 5:30 in the morning, drinks tea, helps his wife with household work (cleaning house) and goes to work by 8:00 am.
He does farming till 12-12:30 pm and has lunch. He rests for 45mins - 1 hour and again gets back to work. He will reach home by 5:00pm and watches television and goes for a walk with his friends till 8:00pm, comes back and has dinner and sleeps by 10:00pm
The above mentioned complains haven’t effected his daily routine yet.
[8/12, 14:29] +91 96760 48138: Ip no:20230820084
A 44 year old male
C/o sob at rest since 10 days
C/o pf chest pain radiating to back since 10 days and occasionally palpitations
Associated with cough with sputum
And not associated with fever vomitings
Not k/c/o Dm, HTN ,epilepsy, asthma, CVD, CVA
On examination
Pt is c/c/c
PR - 91bpm
RR - 14cpm
Bp - 130/70mmHg
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy
Cvs - S1S2 +, no murmurs
RS - BAE+, NVBS
Cns - NFND
Per abdomen -soft and non tender
Advice
Symptomatic treatment
Daily routine
he is sarpanch of the village near valligonda
He wakes up early in the morning goes to walking and later he freshens up has his breakfast at 9am and goes to attend gram panchayat meetings if any or guiding the workers to do the work for the development of village has lunch at 1pm and dinner at 9 pm sleeps at 10 pm
His daily routine is not disturbed by the above mentioned complains
[8/12, 14:33] +91 96760 48138: Op no: 20230820090
A 33 year old female came with chief complaints of chest pain non radiating to left arm. Increased pain on intake of spicy food.No complaints of fever, vomitings, no h/o SOB,orthopnea,PND.
N/k/C/O HTN,DM, thyroid disorders, seizures,TB,Asthama
On Examination -
Patient is conscious, coherent, cooperative
Temp: afebrile
BP: 110/60mmHg
Pr: 103bpm
No signs of pallor, icterus, cyanosis, clubbing and lymphadenopathy.
CVS: S1,S2 heard, No murmurs
RS : bae+ , NVBS heard
P/a : soft,non tender,bowel sounds+
CNS : NFAD
Daily routine-
The patient is a homemaker. She wakes up at 5:30 am, freshens up, nd does her household work by 8:00 and after that she has her breakfast at 8:30am. After that she watches tv amd spends time with family. She has her lunch at 2 pm and sleeps till 5:00 pm. If there's any requirement regarding groceries she goes to marketplace after 5 and has her dinner by 8:00 pm. She goes to bed by 9:00 pm. Her daily activities don't get disturbed because of the complaints.
Her daily routine is not affected by the above mentioned complaints
[8/12, 15:38] Lasya Reddy: Op no: 20230816332
A 31 year pld female came with c/o pf headache since 2 months , diffuse type associated with nausea and photopobia,no h/o pf phonophobia, loose stools, constipation, burning micturition
N/k/C/O HTN,DM, thyroid disorders, seizures,TB,Asthama
On Examination -
Patient is conscious, coherent, cooperative
Temp: afebrile
BP: 120/80mmHg
Pr: 98bpm
No signs of pallor, icterus, cyanosis, clubbing and lymphadenopathy.
CVS: S1,S2 heard, No murmurs
RS : bae+ , NVBS heard
P/a : soft,non tender,bowel sounds+
CNS : NFAD
Daily routine- pateint is home maker
Patient wakes up at 7 and freshens up and does her household chores and has her breakfast by 8 am mostly eats idilli /dosa . Then spends her time by taking rest or helping in household chores , 1 pm she has herlunch , then takes nap till 5 pm after waking up she drinks his tea and then spends her time talking with her neighbours , then by 9 pm eats her dinner and goes to sleep by 10:00 pm .
Her daily routine is not affected by the above mentioned complains
Advice:
Patient managed conservatively with medication and adviced adequate hydration
[8/12, 15:57] +91 96760 48138: Op no 20230818780
A 21 year old female came with
C/o 0f passage of stools 3 to 4 times a day
C/o of abdominal pain relieved after passing of stools
N/o history of nausea ,fever cough and cold,vomiting burning micturition, no h/o sob, headache
Not a k/c/o -HTN, DM, CAD, CVA, thyroid problems, asthma, epilepsy
Examination: Patient is conscious, coherent, cooperative
Temp: Afebrile
Pr: 69 bpm
Bp: 120/80 mm Hg
Rr: 16 cpm
No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy,
Cvs:-S1 S2 heard, no added sounds
Rs:-BAE+, NVBS +
P/a: - soft, non tender
CNS: - NFD
Daily routine-
Patient is a nursing student
She wakes up at 6:00 in the morning, uses mobile for a while and freshens up by 7:30 and has breakfast before leaving for college at 8:00am. Attends classes till 1pm and has her lunch by 1pm.
She has snacks in the evening around 5pm and goes back to home and does her academic works after that
She has her dinner by 9:00 pm and goes to sleep by 10:00 pm.
The above mentioned complains have not effected her daily routine yet.
[8/12, 16:28] +91 99081 59666: requesting all the interns to take internship completion assessment on the last 2 days of posting in general medicine department and your extensions will be finalised at the end of your general medicine posting of 60 days.
[8/12, 16:52] Dr Rakesh Biswas Sir: Also to log every offline activity around their patients into this system 'so that later they can provide the tracebacks of all their work and also so that it helps us to use that logged work to take better decisions about the patients
Also present their cases daily offline in the rounds
Prepare osce around their cases as shared in @Vaishnavi Maguluri 's portfolio
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