Medicine opd cases

Unit postings

 17 july 2023

[7/17, 12:00 PM] : Op number -20230725563

A 75 year old female patient came to OPD with history of head injury 5days back while sweeping

No history of loss of consciousness

No history projectile vomitings

Complaints of tingling sensation of both upperand lowerlimbs

Pasthistory -

 k/c/o Htn since 15 years , on medication amlodipine 5mg

 Not k/c/o DM, Epilepsy, TB,

 CVD

On examination pt is c/c/c

Pulse rate - 82bpm

Bp-140/80mm Hg

Cvs - S1 S2 +, no murmurs

RS -BAE+,NVBS+

CNS 

 B/L pupil - NSRL

Tone - Normal in all limbs

Power  rt     lt

  U.L.   5/5  5/5

  L.L.    5/5   5/5

Reflexes  - 

             B  T  S  K  A  P

 Right. +  +   +         Flexion

 Left.   +  +   +         Flexion

Knee and ankle couldn't be elicited due to injuries

Treatment- symptomatic treatment

Daily routine

She is a homemaker,she wakes up at 7:00am and then  she clean her house and sweep her surroundings to maintain cleanliness 

She has breakfast by 8:30 am and then household work .

She takes her lunch by 

12 :30pm and sleeps for 2hours,again she cleans her house and then she passes her time with neighbours in the evening and has her dinner by 9pm and goes to bed by 10pm

 5days back, while she was cleaning her house , she fell down and got head injury and she was taken to local hospital and treated.

Dr.Sushmitha (SR)

Dr.pavani (pgy2)

Dr.Nithin(pgy1)

[7/17, 12:15 PM] Vandhana 2k18 Kims: Op no :20230726515 

18 year old female came to op with c/o fever since 2 days 

C/o cough with sputum since 1 day not associated with throat pain . 

C/o cold since 1 day 

Fever associated with chills and rigors , relieved on medication.cough with expectoration, sputum is yellowish white in colour, not blood tinged .

On examination:

Bp:110/80mm hg

Pulse : 84 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

Daily routine:

She is a student , wakes up at 6:30 am and has her breakfast by 8 :00 am and goes to college goes home by 6:00 pm eats dinner by 8:00 pm and sleeps at 11:00 pm . Since 2 days she is not going to college because of fever and weakness. 

Advice 

Symptomatic treatment.

Dr Sushmitha (sr)

Dr Pavani (pg y2)

Dr Nithin (pg y1)

[7/17, 12:54 : Op no :20230726466

75 y female came to opd with c/o easy fatiguability and giddiness since 6 days .

Associated with sweating, decreased appetite, constipation.

No h/o LOC, seizures , tingling sensation,decreased urine output .

K/c/o hypothyroidism since 6 years , using thyroxin 50 mcg 

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

On examination:

Bp:100/70mm hg

Pulse : 60 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

Daily routine: 

Wakes up at 5:00 am in the morning,  and does prayer for an hour , has her breakfast at 8: 00 am , prepares lunch and has by 1:00 pm and takes rest for an hour . She has her dinner by 7:00 pm and sleeps at 9:00 pm , since one week she is unable to cook because of giddiness and she is taking rest . 

She is afraid that she might fall . She is unable to do her daily activities.

[7/17, 12:54 PM] Vandhana 2k18 Kims: Op no :20210106227 

37 year old male came to op with c/c of cold since 10 days ,fever since 2 days  which relieved on medication.

H/o dry cough since 8 days and was relieved on medication.

No h/o throat pain 

On examination:

Bp:120/70mm hg

Pulse : 78 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

Daily routine: 

He is a driver by occupation, goes to work by 6:00 am in the morning. He has his breakfast at 9:00 am, lunch at 2:00 pm , cones home by 8:00 pm , has his dinner at 9:30 pm and sleeps at 11:00 pm . 

He is going to work despite being ill .

Advice : symptomatic treatment 

Dr Sushmitha (sr)

Dr Pavani (pg y2)

Dr Nithin ( pg y1)

[7/17, 12:54 PM] Vandhana 2k18 Kims: Op no: 20230725545

80 year old male patient came to opd with c/c of lower backache since 2 -3 months 

Throat irritation since 2 months 

Dry cough occasionally 

C/o burning micturation on and off since 5 years ,not using any medication. 

No h/o fever,cold, chest pain ,sob,palpitations 

Patient is a k/c/o HTN on tab .Telama H 

On examination:

Bp:140/80mm hg

Pulse : 84 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

Daily routine:

He is a member of grampanchayath , he also does political work , He wakes up at 4:00 am in the Morning , goes for walking and he cooks for himself , drinks tea at nearby shop and goes for political meetings . He has his lunch around 1:00pm and  dinner around 8:00 pm , His wife passed away 4 years ago since then he has difficulty in cooking for himself . 

Treatment: 

Symptomatic treatment.

Dr Sushmitha (sr)

Dr Pavani (pg y2)

Dr Nithin (pg y1)

[7/17, 2:19 PM] Kavya Samudrala: Op number - 20230725919

A 30 year old female patient came to the OPD with complaints of

pain abdomen since 4days

Loose stools 2 to 3 episodes since 4days

Nausea sensation since 4days

Fever since 2days

Past history

Not k/c/o DM, HTN, asthma , Tb, Epilepsy, CVD.

She underwent hysterectomy  for AUB 5years back

On examination pt is c/c/c

Pulse rate - 88bpm

Bp - 100/70mm Hg

Cvs - S1S2+, no murmurs

RS - BAE+, NVBS+

Dailyroutine

She is a labourer , she wakes up at 6:00am and she takes rice in the morning by 9clock and goes to work by 10am

She works for 3hours then she takes her lunch at work place and continues her work till evening and then she takes rice at 7pm and goes to sleep by 9pm.

4days back, she ate chicken curry and then she experienced pain in the abdomen and loosestools since 4days, then she went to local rmp and took some unknown medications,not relieved.

Treatment - symptomatic treatment

Dr. Sushmitha (Sr)

Dr.pavani (pgy2)

Dr.Nithin - (pgy1)

[7/17, 2:19 PM] Kavya Samudrala: Opnumber - 20230726593

A 45 year old female patient presented with complaints of h/o head injury due to fall at home .

No complaints of headache

No h/o vomiting

Not k/c/o Dm,Htn,asthma,epilepsy,Tb,

CVD

On examination 

Pt - c/c/c

PR - 82bpm

Bp - 110/80 mm Hg

CVS - S1S2+, no murmurs

RS - BAE+, NVBS+

CNS 

B/L - NSRL

Tone -normal in all four limbs

Power  rt    lt

             5/5  5/5

            5/5   5/5

Reflexes

B    T    S    K    A    P

++  ++  ++  ++  ++  Flexion

++  ++  ++  ++  ++  Flexion

Treatment - symptomatic treatment

Daily routine

She is a farmer, she wakes up at 6am and has her breakfast by 9am and goes for her work by 10am and takes her lunch by 1pm at her farming place and goes to home by 6pm and has her dinner by 7pm and goes to sleep by 9pm

3days back, while she was using her current water heater she got electric shock, fell down and had headinjury.

Dr. Sushmitha (Sr)

Dr.pavani (pgy2)

Dr. Nithin (pgy1)

[7/17, 2:19 PM] Kavya Samudrala: Op number - 20230725939

A 21 year old female patient presented to opd with complaints of cold and cough since 2days 

Cough -wet cough

C/o fever since 1day

C/o body pains since 1day

Past history - not k/c/o Dm, Htn, asthma, epilepsy, Tb, Cvd.

On examination

Pt is c/c/c

Pulserate - 84bpm

Bp -110/70 mm Hg

Cvs - S1S2+, no murmurs

RS - BAE +, NVBS+

Daily routine

She is a student

She wakes up at 6am and goes to her college by 8am and takes lunch at 1pm , attends her afternoon classes and evening she spends her time with friends, takes her dinner by 8pm and goes to sleep by 11 30pm.

Dr. Sushmitha (Sr)

Dr. Pavani (pgy2)

Dr. Nithin(pgy1)

[7/17, 2:19 PM] Kavya Samudrala: Op number - 20230726516

A 19 year old female patient presented to Opd with complaints of fever since 5days, dry cough since 2days

Pain abdomen, aggravated on taking food.

Past history - not k/c/o Dm, Htn,asthma,Tb, epilepsy

On examination

Pt is c/c/c

Pulserate - 80bpm

Bp - 110/70 mm Hg

CVS - S1 S2 +, no murmurs

RS - BAE+, NVBS+

Treatment - symptomatic treatment

Daily routine - 

She is a student, wakes up at 5am and pray to god at 6am

She goes to her classes at 9am and takes her lunch by 1pm ,continues with her afternoon classes

Then in the evening , she paints some pictures or studies some time then takes her dinner by 9pm and goes to sleep by 11pm.

Dr. Sushmitha (Sr)

Dr.pavani (pgy1)

Dr. Nithin (pgy2)

[7/17, 3:10 PM] Vandhana 2k18 Kims: 16 y old female came to op with c/c of headache right sided since 1 week lasting for 5 min and relieved by itself 

No tingling sensation, neck pain 

C/o of pain abdomen in epigastric and umbilical regions .

No burning micturation 

Not associated with nausea ,vomitings ,constipation  ,cold,cough , fever , no blurring of vision 

Normal menstrual history, regular cycles 

On examination:

Bp:110/80mm hg

Pulse : 84 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/a : tenderness present around the umbilical region  and left hypochondrium .

Daily routine: 

She is a student she wakes up at 6:00 am to study and has her breakfast by 8:00 am in the morning, lunch at 1:00 pm and dinner at 8:00 pm , she is not able to study because of headache but she is going to College despite being sick . Her daily routine is not much altered . 

Advice :

Symptomatic treatment. 

Dr Sushmitha (sr)

Dr Pavani (pg y2)

Dr Nithin (pg y1)

[7/17, 3:56 PM] Vandhana 2k18 Kims: Op no :20210111899

33 year female came to opd with c/c of burning sensation of throat and epigastric region  since 10 days associated with nausea .

On examination:

Bp:110/70mm hg

Pulse : 78 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

Daily routine: 

She is a school teacher , she wakes up at 6:00 am and has her breakfast at 7:30 am and goes to school by 8:00 am , she has her lunch at 1:00 pm and comes home at 5:00 pm , prepares dinner and has her dinner at 8:00 pm and sleeps at 9:00 pm 

She is going to school even when she is ill her daily activities are not disturbed, but she has discomfort the entire day. 

Advice : symptomatic Treatment 

Dr Sushmitha (sr)

Dr Pavani (pg y2)

Dr Nithin ( pg y1)

 18 july 2023

[7/18, 9:54 AM] Shivani Reddy. S kims: Op no :20210115755

32 year female came to opd with C/O of  SOB grade2  with chest tightness on and off  and cough since 2 months .

C/O polyuria, cold intolerance,palpitations

No H/O weightloss/weight gain and constipation.

K/C/O Renal calculi since 3-4 years.

K/C/O hypothyroidism since 9 years and is on medication

On examination:

Bp:110/70mm hg

Pulse : 78 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She works as a sales manager in a ayurvedic shop .She wakes up at 4:00 am and has her breakfast at 9:00 am and goes to her work  at 10:00 am , she has her lunch at 1:00 pm and comes back from her work  at 5:00 pm , prepares dinner and has her dinner at 9:00 pm and sleeps at 10:00 pm 

She is going to work even when she is ill her daily activities are not disturbed, but she has discomfort the entire day. 

Advice : symptomatic Treatment 

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)

[7/18, 10:09 AM] Saranya Mukarjee KIMS: OP number:20230727410

A 70 year old lady came with complaints of left loin pain since the past 3 months, 

Pain was insedious in onset, dragging type, associated with lower limb pain 

Since then the patient also complains of loss of appetite , shortness of breath ( grade 2 )

Patient has complaints of bloating sensation and  diarrhoea after eating spicy food 

No complaints fever,no decreased urine output,pain abdomen and burning micturition.

N/K/C/O HTN ,DM, Asthma

On Examination: 

Patient is conscious,coherent,cooperative pallor +  ,no icterus,cyanosis,clubbing,lymphadenopathy

Temperature: Afebrile

PR:84bpm

BP:110/60mmg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+ 

Daily routine:

Occupation: Patient gets up at 6 am , in their household the practice is to have rice at all meals including breakfast

She has her breakfast at 9 am ( rice + curry / pickle ) , and then goes to work 

( as a daily labourer) , she comes home for lunch at 2 pm ( rice + sambar + curry + pickle )

She goes back to work again.

After coming back in the evening ,she freshens up and spends time with her grandchildren

Has dinner at 8pm .

How the pain brought a change in her daily routine :

Since she developed the loin pain, she has stopped going to her daily work , she confines herself to her home , spends more time lying down on bed, fatigue + ,her food intake has reduced ( loss of appetite + )sleep is disturbed.

Investigations sent.

Hemogram

Usg Abdomen

Ecg

Cue

Chest xray

Reports awaited.

Empirically Symptomatic treatment has been suggested.

Dr.Haripriya

Dr.Govardhini

[7/18, 10:28 AM] Shivani Reddy. S kims: Op no :20230727408

A 74 year old male came to opd with C/O of  SOB grade2 with cough with expectoration on and off  and cough since 5-6 months.

C/O chestpain,tightness of chest ,palpitations,abdominal pain  since 5-6 months. 

K/C/O hypertension  since 3 years and is on medication.

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

On examination:

Bp:120/70mm hg

Pulse : 80 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

He works as a carpenter. He wakes up at 4:00 am ,drinks some tea at 7:00am and starts doing his carpenter work .He has his breakfast at 10:00 am and continues his work.He  has his lunch at 1pm and completes his work at 4 pm and eats some food at 4pm and dinner at 9pm and goes to sleep .

His daily routine is not affected by his symptoms but he experiences SOB and chesttightness while working.

He continues to work despite his discomfort 

Advice : symptomatic Treatment 

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)

[7/18, 10:34 AM] Rakesh Biswas Sir: Visceral fat and biceps lateral view? PaJR group link?

[7/18, 10:35 AM] Rakesh Biswas Sir: By your last line you mean her shortness of breath at rest and at lunch and sleep and work are the same?

[7/18, 10:39 AM] Shivani Reddy. S kims: No she has SOB (grade2)only while working.

[7/18, 10:41 AM] Rakesh Biswas Sir: What work does a sales manager do that can cause dyspnoea?

[7/18, 10:43 AM] Shivani Reddy. S kims: She lifts heavy objects in that shop sir

[7/18, 10:44 AM] Saranya Mukarjee KIMS: Op number : 20230727854

A 45 year old lady came with the complaints of leg swelling since 6 months , facial puffiness since 6 months.

Patient complains of facial puffiness more in the morning hours.

Pedal edema +

Loss of appetite + 

SOB after physical work and  after food intake + 

Bloating sensation +

Abdominal fullness +

No h/o Fever 

No h/o Decreased urine output 

H/O USE OF NSAIDS ( on a daily basis ) for 5 years i/v/o body pains 

N/k/c/o dm , htn , asthma , tb , cad 

Patient is a professional cook , her day begins quite early in the morning when she freshens up , finishes up all her household chores and goes to the work place ( she cooks at tiffin centres and also at family functions ) ,she has lunch there itself , comes home in the late afternoon / evening and gets back to finishing the works at home, 

By the time it is night ,she feels too tired from all the day's work , and experiences body pain ,for which she pops in an NSAID tablet and goes to sleep .

Patient used to take mixed diet , 1 year back she had an exematous skin rash for which she visited an rmp , who adviced her to reduce her non veg intake, since then she has been taking only vegetarian diet.

Effect of disease on her daily routine :

Since the past 6 months she was stopped doing her professional work since she feels fatigued very easily .

O/e :

Patient is conscious,  coherent, cooperative , moderate built, 

Pedal edema +

Afebrile 

BP 120/70 mm Hg

Pulse 78 bpm

Rr 14 cpm

CVS: s1 s2 +

Cns : NAD

Rs : BAE + , NVBS +

Investigations sent : 

Hemogram, RFT, CUE, ECG,CXR,USG abdomen

Advice

To be reviwed with reports (awaited )

Symptomatic treatment 

Dr.Haripriya

Dr.Govardhini

[7/18, 10:46 AM] Rakesh Biswas Sir: See the important detail we may leave out when we don't detail the patient's actual workflow

[7/18, 11:13 AM] Shivani Reddy. S kims: Op no :20230727942

A 58 year old male came to opd with C/O of  sorethroat,  headache and cold since 5-6 days.

C/O nose block,mucus discharge on and off , headache in frontal and parietal region ,burning micturition .

No H/O running nose , photophobia , vomitings, abdominal pain and constipation.

No H/O pedal edema and decreased urine output.

N/K/C/O DM ,HTN,CAD ,epilepsy and TB .

On examination:

Bp:120/70mm hg

Pulse : 80 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

He works as a farmer. He wakes up at 7:00 am ,has his breakfast at 9:00am and goes to his work .He has his lunch at 12pm and comes back to home at 5 pm, has his dinner at 7 pm and goes to sleep by 10pm.

Since 5 days he is unable to go to his work due to his severe headache and cold.He stays at his home and prefers taking rest since  5 days.

Advice : symptomatic Treatment 

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)

[7/18, 11:23 AM] Saranya Mukarjee KIMS: Op number : 20230728437

A 38 year old female came with the complaints of headache associated with neck pain since 20 days.

Headache in occipital region ,radiating to neck , photophobia + , phonophobia - , vomitings - , cough - , facial Heaviness- , watering of eyes - 

Patient is a K/C/O Htn since 1 year on regular antihypertensive medication ( details not available )

How was the diagnosis of HTN made :

1 year back, one day she experienced severe headache and neck pain for which she went to an RMP ,on checking BP was 200 /140  mm Hg

She was taken to a local hospital , admitted for one day, and released after control of BP

N/k/c/o DM 2 , Asthma , CAD , TB

Daily Routine :

She gets up at 5 am , takes a bath, does household chores , Has tea at 7am , gets lunch boxes ready for her children , 

Has breakfast at 9 am, then she goes to agricultural fields for work, according to the season , her work involves planting the seeds ,ploughing, reeping the crops 

She has lunch at 2 pm

Comes back home at around 4 pm

Finishes the remaining household chores,prepares dinner ,

Has dinner by 8 pm and goes to bed.

Effect of her symptoms in her daily life :

Due to headache and neck pain, she is unable to do her usual work at the agricultural work in the fields  since most of the work involves cervical spine bending.

O/e :

Patient is conscious,  coherent, cooperative , moderate built, no pallor,icterus,clubbing,koilonychia,lympadenopathy, 

Pedal edema 

Afebrile 

BP 130/70 mm Hg

Pulse 78 bpm

Rr 14 cpm

CVS: s1 s2 +

Cns : NAD

Rs : BAE + , NVBS

Advice

Symptomatic treatment 

Dr.Haripriya

Dr.Govardhini

[7/18, 11:55 AM] Saranya Mukarjee KIMS: Op : 20230728498

A 24 years old male patient came to opd with 

-C/o fever since 1 day

Cough , cold since 2 days.

Fever of low grade ,  associated with expectoration ( scanty in amount , white in colour , no foul smell ) ,

Sore throat +

No history of

Vomiting, pronounced bodypains, headache abdominal pain , diarrhoea , burning micturition.

Past history-

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

On examination 

Patient is conscious,coherent and cooperative 

Temp- 100 deg F

PR-90 BPM

Bp- 110/70mmhg

RR-16cpm 

Cvs-S1,S2 heard, no murmurs 

Resp- BAE+ , NVBS heard 

P/A- soft , nontender  

Daily routine- 

He wakes up at 6am, takes a bath, has breakfast at 7 am. He works as a welding technician in a factory, he has his lunch at 1 pm, takes some rest and gets back to work , gets back to home at 5.30pm ,Later in the evening he has a cup of tea at around 6. Slhe eats dinner by 7 and sleeps by 9. His work routine hasn’t changed due to her weakness.

Advice-

Symptomatic treatment

Dr.Nikitha

Dr. Haripriya

Dr. Govardhini

[7/18, 12:04 PM] Shivani Reddy. S kims: Op no :20230728495

A 27 year old female came to opd with C/O of  headache with neckpain and giddiness and sweating  since one week.

Headache is diffuse more on right side radiating to posterior side of neck.

C/O low grade fever with cough and nausea.

No H/O photophobia , phonophobia, blurring of vision and watering of eyes and vomiting.

No H/O chills and rigor, sorethroat, SOB and palpitations ,diarrhoea and burning micturition.

K/C/O hypothyroidism since 4 years and is on medication.

  

N/K/C/O DM ,HTN,CAD ,epilepsy and TB .

On examination:

Bp:120/70mm hg

Pulse : 90 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She is a housewife.She wakes up at 6 am ,has her breakfast at 8 am and completes her daily household chores by 12 and has her lunch at 2 am .She has her dinner at 8 and goes to sleep by 10 pm.

Her daily routine is not much affected by her symptoms but while doing her household chores she experiences sweating and giddiness for which she takes  some break (1hr) and sits for a while ,drinks some water and continues to do her work.

Advice : symptomatic treatment 

Dr.Nikitha(SR)

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)

[7/18, 12:47 PM] Shivani Reddy. S kims: Op no :20210217756

A 45 year old female came to opd with C/O of high grad intermittent fever since 1 week .

No C/O  sore throat , chills and rigor ,cough ,cold and abdominal pain , vomitings and diarrhoea

  

N/K/C/O DM ,HTN,CAD ,epilepsy and TB .

On examination:

Bp:120/70mm hg

Pulse : 80 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She is a farmer by her occupation.She wakes up at 6 am  completes her household chores by 10 am and has her breakfast at 10:30 am.She goes to her farming work at 11 am and in between her work she has her lunch at 1 pm.She comes back to home from her work by 6 pm, has her dinner at 8 pm and sleeps by 10 pm. 

Due to her fever she stopped going to her work since 10 days and  she stays at home and takes rest.

Advice : symptomatic treatment 

Dr.Nikitha(SR)

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)

[7/18, 3:00 PM] Saranya Mukarjee KIMS: OP number:20230728947

A 39 year old Male came to opd with complaints of pain in the left chest localised to a point since 2 days .

Pain is of pricking type,intermittent in nature,non radiating to jaw or arm

Not associated with increase during breathing.

No complaints of palpitations, shortness of breath , Fever, Coryza, excessive sweating , feeling of impending doom, pain abdomen ,weight loss, loss of appetite

N/K/C/O HTN  DM ASTHMA TB EPILEPSY CVD

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile

PR:70bpm

BP:120/70mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

Occupation: He has his  business

Patient wakes up at 6am, has breakfast at 7 am and goes to work at 8am am has lunch at 1pm, comes back home at 5pm have dinner at 8 pm and goes to sleep at 10pm.

His work involves travelling as well,

Since the last two days he was travelling for his work while this chest pain  made him worried hence he came to seek medical advice.

Advise:

Symptomatic Treatment 

Dr.Nikitha ( SR )

Dr.Haripriya ( PGY2 )

Dr.Govardhini ( PGY1 )

[7/18, 3:12 PM] Shivani Reddy. S kims: Op no :20230729013

A 38 year old female came to opd with C/O of neckpain which is dragging type, non radiating a/o with tingling and numbness since 1 year

No H/O nausea, vomiting, photophobia and phonophobia.

No H/O tingling and numbness in upper and lower limbs .

  

N/K/C/O DM ,HTN,CAD ,epilepsy and TB .

On examination:

Bp:110/70mm hg

Pulse : 80 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :S1S2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She is a farmer by her occupation.She wakes up at 6 am  completes her household chores by 11am and has her breakfast at 11:00 am.She goes to her farming work at 11 am and in between her work she has her lunch at 1 pm.She comes back to home from her work by 6 pm, has her dinner at 8 pm and sleeps by 10 pm. 

During her work she constantly lifts heavy weights(above 60kg) .Now due to her neck pain she couldnot even lift 1kg weight.She complains of pain only while lifting weights .So she stopped lifting weights but continues to do her daily works and goes to work daily

Advice : 

1)symptomatic treatment 

2)Physiotherapy

Dr.Nikitha(SR)

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)

[7/18, 3:38 PM] Saranya Mukarjee KIMS: OP number:20230729035

A 15 year old girl came to opd with complaints of fever since today morning.

Fever is of low grade , associated with chills and rigor.

Complaints of cold and cough since 1 week, relieved on medication.

History of throat pain since 1 week.

C/o vomitings : 4 episodes, content of vomitus : food particles 

No c/o loose stools , pain abdomen , burning micturition

No complaints of significant unintentional weight loss, loss of appetite

N/K/C/O DM type 1 ,asthma , epilepsy 

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile ( patient has taken a dose of antipyretic medication )

PR:70bpm

BP:120/70mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

She is a school going student. She stays in hostel,

She gets up at 6 am ,gets ready for school, has breakfast at 7 am , attends her classes , has lunch at 12 noon, attends the afternoon classes , takes snacks at 4pm ,engages in outdoor games in the evening, completes her homework, has dinner at 8 pm and goes to bed.

Since today morning she has been feeling unwell and weak due to the fever ,hence she was brought to the opd by the hostel-in- charge.

Advise:

Symptomatic Treatment 

Dr.Nikitha ( SR )

Dr.Haripriya ( PGY2 )

Dr.Govardhini ( PGY1 )

19 july 2023

[7/19, 9:25 AM] Lasya Sakilam Kims: OP number:20210525364

A 18 year old girl came to opd with complaints of generalised weaknesssince 3 days .

No H/O fever, headache, vomitings, loose stools, chest pain, palpitations 

No complaints of significant unintentional weight loss, loss of appetite

N/K/C/O DM type 1 ,asthma , epilepsy 

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile ( patient has taken a dose of antipyretic medication )

PR:78 bpm

BP:110/70mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

She is a degree student. She stays in hostel,

She gets up at 7:30 am ,gets ready for school, has breakfast at 8 am ,goes  attends her classes from 9  , has lunch at 1 afternoon, attends the afternoon classes , takes snacks at 5 pm , completes her homework, has dinner at 8 pm and goes to bed at 10 pm.

Advise:

Symptomatic Treatment 

Dr.Zain ( SR )

Dr. Narsimha ( PGY2 )

Dr.Lohith ( PGY1 )

[7/19, 9:56 AM] Lasya Sakilam Kims: OP number:20230729278

A 55 year old female came to opd with complaints of high grade fever  since yesterday night not a/w chills and rigors, relieved temporarily on medication .

C/o dry cough, intermittent present since yesterday 

C/o body pains present 

No 

No H/O cold, burning micturation , vomitings, loose stools

No complaints of significant unintentional weight loss, loss of appetite

K/C/O HTN since 6 years on Amlodipine 5 mg PO/OD

N/K/C/O DM type 1 ,asthma , epilepsy 

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile ( patient has taken a dose of antipyretic medication )

PR:94 bpm

BP:130/70mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

She works at anganwadi.

She gets up at 5:30 am ,cleans the house and cooks , has breakfast at 8 am ,goes to work at 9am  , has lunch at 1 afternoon ,comes home at 4 pm, takes snacks at 5 pm , cooks dinner and has dinner at 8 pm and goes to bed at 9 pm.

Advise:

Plenty of oral fluids 

Symptomatic Treatment 

Dr.Zain ( SR )

Dr. Narsimha ( PGY2 )

Dr.Lohith ( PGY1 )

[7/19, 10:21 AM] Sarbesh Kims: Patient ID: 20230729285

Patient Complaints:

The patient has been experiencing a mild fever for the past 3 weeks, with occasional occurrences, mainly at night.

The patient has had a cough for 3 weeks, which is worse at night and has worsened over the last week. The cough is associated with a cold and brings up mucus that sometimes contains traces of blood.

The patient has a history of body pains and a burning sensation while urinating.

There is no history of abdominal pain or loose stools.

For the past 3 days, the patient has been passing hard stools that contain traces of blood.

The patient has experienced 2 episodes of vomiting in the last 2 days. The vomit contained food particles, was not blood-stained, and was not associated with a bile-like color. Nausea was also present during these episodes.

Medical Examination Findings:

Cardiovascular System: Normal heart sounds (S1S2), no murmurs.

Respiratory System: Normal breath sounds, no added sounds.

Abdomen: Soft, non-tender.

Central Nervous System: Normal higher mental functions, no focal neurological deficits.

Patient's Daily Routine:

The patient is a nursing student and wakes up at 6:30 am.

Breakfast is taken at 7:00 am.

Classes are attended from 8:00 am to 12:30 pm.

Lunch is at 1:00 pm.

Classes are attended again from 1:30 pm to 4:00 pm.

From 4:00 pm to 6:00 pm, the patient rests. During this rest period, the patient has been experiencing cough and headaches for the past three weeks.

From 6:00 pm to 7:30 pm, the patient either studies or attends to personal matters.

The patient complains of fever before dinner.

Dinner is at 7:30 pm.

From 8:00 pm to 10:30 pm, the patient studies.

The patient goes to sleep by 11:00 pm.

Additional Complaints:

The patient has tonsil irritation and pain while swallowing food, leading to the avoidance of snacks. The overall food intake has reduced.

Overall, the patient has been experiencing a low-grade fever for three weeks, along with a cough that has worsened recently, especially at night. There are traces of blood in the mucus brought up by the cough. Additionally, the patient has a history of body pains, burning urination, hard stools with blood traces, and recent episodes of non-blood-stained vomiting with nausea. The patient has also been experiencing irritation in the tonsils, leading to pain during food swallowing, resulting in reduced food intake.

[7/19, 10:44 AM] Lasya Sakilam Kims: OP number:20210202702

A 62 year old male came to opd with complaints of loose stools since 4 days small quantity, watery stools a/w mild pain abdomen.

No C/o fever, vomitings

No H/O cold, burning micturation , vomitings, loose stools

No complaints of significant unintentional weight loss, loss of appetite

K/C/O HTN since 6 years on Temlmisartan 40 mg+hydrochhlorthiazide 12.5 mg PO/OD

K/C/O DM since 6 years ON Metformin 500 mg +Glimiperide 1 mg PO/BD 

N/K/C/O asthma , epilepsy, CVA

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile ( patient has taken a dose of antipyretic medication )

PR:102 bpm

BP:130/100mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

He was a lorry driver. He stopped working following hip fracture (due to fall at home) 1 Yr back. Currently he oversees the work at his farm .He gets up at 5:30 am, has breakfast at 7 am ,goes to field at 8 am  ,comes home by 11 am , watches TV has lunch at 1 afternoon, and sleeps for sometime, takes snacks at 5 pm ,watches TV, dinner at 8 pm and goes to bed at 10 pm.

Due to his complaints patient didn't go to his farm from 2 days 

Advise:

Symptomatic Treatment 

Dr.Zain ( SR )

Dr. Narsimha ( PGY2 )

Dr.Lohith ( PGY1 )

[7/19, 10:46 AM] Sarbesh Kims: Patient's OP No.: 20230729728

18-year-old female undergraduate student came with Chief Complaints: Low-grade fever for the past 2 days, intermittent type, with no diurnal variation, temporarily relieved with medication. No complaints of burning micturition, cold, or cough with chills & rigors.

History of vomiting 2 days ago, which contained food particles, non-bile stained, and non-projectile. No history of loose stools or rashes. Also, a history of intermittent abdominal pain in the umbilical region with a burning sensation.

Not a known case of TB, epilepsy, hypertension, thyroid disorder, DM, CAD

Clinical Findings:

- Cardiovascular System (CVS): S1S2 heard, no murmurs detected.

- Respiratory System (RS): Breath sounds are present, no added sounds.

- Abdominal Examination (PA): Abdomen is soft and non-tender.

Patient's Daily Routine:

The patient is an 18-year-old female undergraduate student with the following daily routine:

- Wakes up at 6:30 am.

- Breakfast at 7:30 am.

- Attends classes from 8 am to 1 pm, skipping the tea break at 11 am.

- Lunch from 1 pm to 2 pm.

- Continues classes from 2 pm to 4 pm.

- Has snacks at 4:30 pm.

- Studies from 4:30 pm to 7:30 pm.

- Dinner at 7:30 pm.

- Socializes with friends and handles personal tasks until 10:30 pm.

- Sleeps by 11 pm.

No recent changes in the daily routine have been reported.

[7/19, 11:32 AM] Lasya Sakilam Kims: OP number:2023020347

A 40 year old female came to opd with complaints of pain in epigastrium since 1 year which has aggravated on spicy food intake and relieved temporarily on medication 

Belching+, regurgitation +

No c/o fever, vomiting, loose stools 

No complaints of significant unintentional weight loss, loss of appetite

N/K/C/O DM, HTN, asthma , epilepsy, CVA

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile

PR:84 bpm

BP:110/80mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

She is an agriculture worker. He gets up at 6 am. 

She cleans and cooks at home goes to farm at 10 am . She has lunch at 1 afternoon and works again. She comes home at 5 pm. She has dinner at 8 pm and goes to bed at 10 pm.

No recent changes in the daily routine have been reported 

Advise:

Symptomatic Treatment 

Dr.Zain ( SR )

Dr. Narsimha ( PGY2 )

Dr.Lohith ( PGY1 )

[7/19, 11:32 AM] Lasya Sakilam Kims: OP number:20230729784

A 29 year old male came to opd with complaints of chest pain since 6 months which has aggravated since 2 months, retrosternal pain mainly during morning time, temporarily relieved on medication ( medication not known) .

C/O pain on movement from lying down /bending to sitting position 

No C/O sob, palpitations, orthopnea, PND 

No complaints of significant unintentional weight loss, loss of appetite

N/K/C/O DM, HTN, asthma , epilepsy, CVA

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile 

PR:86 bpm

BP:120/80mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

He is an agriculture work. He gets up at 6 am, goes to farm ,comes home by 8 am , has breakfast at 9 am and goes to farm again. He has lunch at 1 afternoon and sleeps for some time. He goes back to farm from 3-8 again. He has dinner at 8 pm and goes to bed at 11 pm.

No recent changes in the daily routine have been reported 

Advise:

Symptomatic Treatment 

Dr.Zain ( SR )

Dr. Narsimha ( PGY2 )

Dr.Lohith ( PGY1 )

[7/19, 11:56 AM] Sarbesh Kims: Op no.: 20230730242

Patient Profile:

A 19-year-old male nursing student came with complaints of pain in the right upper back since this morning, which worsens with neck movements and movements of his right upper limb above the head. 

Not a K/C/O of hypertension, diabetes, tuberculosis, epilepsy, or asthma.

O/E:- the patient is conscious, coherent, and cooperative. 

BP:-  120/80 mmHg  

Pr:- 86 bpm. 

CVS S1 S2 heard with no murmurs. 

RS:- BAE with no added sounds.

P/A:-  soft and non-tender. 

CNS :- NFND

Tenderness over the supraspinatus region.

Daily Routine:

The patient follows a consistent daily routine:

- Wakes up at 7:00 am

- Freshens up and has breakfast at 7:30 am

- Attends classes from 8:00 am to 1:00 pm

- Lunch at 1:00 pm

- Attends classes again from 2:00 pm to 4:00 pm

- Freshens up and has snacks at 4:30 pm

- Takes a nap from 5:00 pm to 7:00 pm

- Dinner at 7:00 pm

- Engages in studies or personal activities from 7:30 pm to 11:00 pm

- Watch movies from 11:00 pm to 1:00 am

- Sleeps by 1:00 am.

No changes in the patient's daily routine

[7/19, 12:09 PM] Sarbesh Kims: Op no. 20230730241

Patient Profile:

A 20-year-old male nursing student came with a complaint of a sore throat, experiencing irritation for the past 3 days. 

He also gives a history  of having a dry cough intermittently for the 3 days, no diurnal variation .

 The patient gives no h/o fever, headache, vomiting, or loose stools. 

There is no history of diabetes, hypertension, tuberculosis, epilepsy, thyroid disorders, or asthma.

O/E:- 

Pt. Is C/C/C

BP:-  110/60 mmHg 

Pr:-  68 bpm.  

CVS:- S1 and S2 heard, no murmurs .  

RS:- BAE ,no additional sounds. 

P/A:-  soft and not tender.

CNS:- NFND

Daily Routine:

The patient's daily routine is as follows:

- Wakes up at 7:00 am

- Freshens up and has breakfast at 7:30 am

- Attends classes from 8:00 am to 12:30 pm

- Lunch at 1:00 pm

- Attends classes again from 2:00 pm to 4:00 pm

- After class, he freshens up and has snacks at 4:30 pm

- Engages in volleyball sessions from 5:00 pm to 7:00 pm, three times a week. On other days, he takes a nap during this time.

- Between 7:00 pm and 9:30 pm, he studies or works on personal tasks.

- At 9:30 pm, he has dinner.

- After dinner, he spends time talking with his parents before going to sleep at 11:30 pm.

[7/19, 2:13 PM] Sarbesh Kims: Op no.: 20230730344

Chief Complaint:

A 60-year-old female homemaker presented with a low-grade fever, intermittent type, for the past 10 days. Fever is relieved with medication. She also complains of vomiting 1-2 times a day, with vomitus containing food particles, non-projectile, and non-bilious. Additionally, she has experienced a loss of appetite and nausea. No history of cold, cough, loose stools, or burning micturition. No history of shortness of breath, chest pain, palpitations, or orthopnea. The patient has no known medical history of hypertension, diabetes, tuberculosis, cerebrovascular accident , coronary artery disease, epilepsy, or asthma.

Clinical Examination:

- Blood Pressure: 150/100 mmHg

- Pulse Rate: 74 bpm

- Cardiovascular System: S1 and S2 heart sounds heard, no murmurs detected.

- Respiratory System: Breath sounds are normal, no additional sounds.

- Abdomen: Soft and non-tender on palpation.

Daily Routine:

The patient follows a daily routine as follows:

- Wakes up at 6 am and engages in household chores until 8 am.

- After breakfast, she prepares lunch and takes a short rest.

- Lunch is consumed at 1 pm.

- An afternoon nap is taken from 2 to 4 pm.

- At 5 pm, she has snacks and tea while preparing dinner and watching TV.

- Dinner is consumed at 8 pm, and she goes to bed by 9 pm.

[7/19, 3:19 PM] Sarbesh Kims: Op. No.: 20230730765

Patient Profile:

A 30-year-old female with a complaint of chest pain for the past 3 days during both inspiration and expiration. The pain is described as a dragging type, intermittent, lasting for 5 to 6 seconds. Additionally, she experiences shortness of breath (Grade II-III) during ordinary activities, which does not improve with rest. There is no history of fever, cough, vomiting, or loose stools. The patient has no known medical history of hypertension, diabetes mellitus, epilepsy, asthma, thyroid disorders, cerebrovascular accidents, coronary artery disease, or tuberculosis.

Clinical Examination:

- Blood Pressure: 120/70 mmHg

- Pulse Rate: 82 bpm

Cardiovascular System:

- S1S2 heart sounds heard, with no murmurs detected

Respiratory System:

- Bilateral air entry present, no added sounds detected

Patient's Daily Routine:

The patient is a 30-year-old female agriculture worker with the following daily routine:

- Wakes up at 4 am

- Engages in household chores and cooking until breakfast at 7 am

- Goes to the farm at 8 am

- Has lunch at 1 pm and continues working

- Returns home at 5 pm

- Has dinner at 8 pm

- Goes to bed at 10 pm

- No recent changes in the daily routine have been reported.

20 july 2023

[7/20, 10:07 AM] Shareena Kims: Op number:20230731116

Chief complaint: 

A 45 year old male , farmer by occupation presented with burning sensation in Palms and soles since 10 days .

He also complaints of low grade fever not associated with chills and rigor.

He also complaints of epigastric pain, burning type since 1 month, intermittent ,no palpitations , no sweating,no shortness of breath .

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

Clinical examination:

Blood pressure:110/70 mmhg

PR: 80 BPM

CVS:S1 and S 2 heart sounds heard ,no murmurs .

RS: Breath sounds are normal,no additional sounds .

Abdomen:soft and non tender on palpation .

Daily routine:

Patient wakes up at 6 in the morning goes to work and comes back at 9 and has his breakfast and again goes back to work.

He has his lunch at 1 in the afternoon and goes back to work and returns home by 5 in the evening.

At 6 he has tea and snacks.

He consumes dinner at 8 and goes to bed by 10.

Treatment:

Symptomatic treatment.

[7/20, 10:45 AM] +91 91007 16817: Op number:20230731459

Chief complaint: 

A 36 year old female who is a housewife presented with c/o left sided chest pain and burning sensation since 1 year

Pain aggravates on eating food and releaves on lying down 

Chest pain radiating to left upper limb.

N/h/o SOB, palpitations,pedal edema , Giddiness

H/o headache -occipital,Aura+,no photophobia 

Not a k/c/o DM,HTN,TB, Epilepsy,CAD,CVA, thyroid abnormalities.

Clinical examination:

Blood pressure:120/70 mmhg

PR: 77 BPM

RR:18/min

CVS:S1 and S 2 heart sounds heard ,no murmurs.

RS: Breath sounds are normal,no additional sounds .

Abdomen:soft and non tender on palpation .

Daily routine:

Patient is a housewife She gets up at 5:30 am ,cleans the house and cooks , has breakfast at 8 am , has lunch at 1 afternoon , takes snacks at 5 pm , cooks dinner and has dinner at 8 pm and goes to bed at 9 pm.

Advice:

Symptomatic treatment

lifestyle modification

Avoid spicy food

[7/20, 10:56 AM] Shareena Kims: Op no :20230728440

A 20 year old female nursing student came with complaint of fever,body pains,loss of appetite, nausea, headache since 1 day.

Fever is low grade,not associated with chills and rigor and relieved by medication.

She complaints of nausea and loss of appetite since 1 day.

Complaints of head ache in frontal region.

No h/o photophobia, watering of eyes,blurred vision.

No h/o vomitings, abdominal pain,sore throat,cold and cough.

No h/o burning micturition.

Not a k/c/o diabetes, hypertension, tuberculosis, epilepsy, thyroid disorders,asthma.

O/E:

Pt is c/c/c 

BP:110/70 mm hg

PR:70 BPM

CVS :S1 and S2 heard ,no murmurs.

RS: BAE , no additional sounds.

P/A: soft and non tender

CNS:NFND

Daily routine:

Patient wakes up at 6:30 in the morning freshens up and has breakfast at 7:30 and attends class at 8 to 1 and has her lunch at 1 and goes back to class by 2 .

After class she comes back at 4 and rests for some time and does her personal tasks and studies till 8 .

She consumes dinner at 8:30 and again studies for some time and talks to parents and goes to bed by 11.

Treatment:

Symptomatic treatment.

[7/20, 10:58 AM] Rakesh Biswas Sir: Is this routine before one year? Has her routine changed due to her symptoms since one year?

[7/20, 11:00 AM] +91 91007 16817: No sir her routine hasn't changed,she is following same routine.

[7/20, 11:20 AM] +91 91007 16817: Op no. 20230731996

A 30 year old male tailor by occupation came with a complaint of Burning micturition since 3 months 

No h/o fever, vomiting,pain abdomen,loose stools

B/L pedal edema Right >left associated with pain ,pitting type 

C/o Giddiness, no variation with posture

N/h/o hearing loss,fall

N/h/o chest pain,SOB, palpitation

H/o Lower backache -took treatment outside (now resolved)

There is no history of diabetes, hypertension, tuberculosis, epilepsy, thyroid disorders, or asthma.

O/E:- 

Pt. Is C/C/C

BP:-  130/80 mmHg 

PR:-  90 bpm.

RR:18/min

CVS:- S1 and S2 heard, no murmurs .  

RS:- BAE ,no additional sounds. 

P/A:-  soft and not tender.

CNS:- NFND

Daily routine- 

He wakes up at 6am and has breakfast at 8 am. He goes to work after breakfast and has lunch at 2PM. He resumes work after lunch and has dinner at 9PM and sleeps by 10PM.

Advice: symptomatic treatment .

[7/20, 11:48 AM] Shareena Kims: Op no :20230421161

A 38 year old female does scrap work at home came with complaints of Headache since 1 week.

Headache mostly left sided in frontal and occipital region.

No h/o aura, photophobia and phonophobia.

N/h/o eye pain .

Headache lasts for 2-4 hrs and then subsides.

No c/o neck pain , vomitings,loose stools,pain in abdomen.

No h/o fever,body pains.

Not a k/c/o diabetes, hypertension.tuberculosis, epilepsy, thyroid disorders,asthma,CAD,CVA.

O/E:

Pt is c/c/c 

BP: 120/80 mmhg

PR:75 bmp

CVS : S1 and S2 heard,no murmurs.

RS:BAE present,no additional sounds.

P/A: soft and non tender

CNS:NAD

Daily routine:

Patient wakes up at 6 in the morning,she does scrap work , at home till 9 in the morning and then has her breakfast, resumes scrap work and at 1 in the afternoon she has her lunch.

She takes break for 2 hours and again does scrap work again till 8 in the night and has dinner at 9 and goes to bed by 10.

Treatment:

Symptomatic treatment

Plenty of oral fluids

[7/20, 1:01 PM] +91 91007 16817: Op no. 20230732124

A 25 year old male farmer by occupation came with a complaint of tingling and numbness in left leg since 1 year.

N/h/o trauma/fall

N/h/o loss of sensation

N/h/o polyuria, polyphagia, polydypsia 

N/k/c/o of diabetes, hypertension, tuberculosis, epilepsy, thyroid disorders, or asthma.

N/h/o weakness or difficulty in walking.

O/E:- 

Pt. Is C/C/C

BP:-  110/80 mmHg 

PR:-  78 bpm.

RR:18/min

CVS:- S1 and S2 heard, no murmurs .  

RS:- BAE ,no additional sounds. 

P/A:-  soft and not tender.

CNS:- NFND

Daily routine- 

He wakes up at 5:30 am has breakfast at 8AM and goes to work. He is an agricultural farmer. He eats lunch at around 1pm and resumes his daily work. He has dinner at 7:30 and sleeps by 10PM. His routine has not been affected by his illness although he is more tired now.

Advice: symptomatic treatment.

[7/20, 2:50 PM] Shareena Kims: Op no: 20230732625 

A 22 year old nursing student came with complaint of loose stools since 5 days , 5 episodes per day , watery ,large volume.

She also complaints of vomitings since 3 days,non projectile,yellowish to white in colour , content - food particles,non blood tinged.

C/o diffuse abdominal pain and headache since 1 day.

N/H/O fever, abdominal pain,giddiness.

N/k/c of DM,HTN, tuberculosis, epilepsy, thyroid disorders,asthma.

O/E:

Pt is c/c/c 

BP:110/80 mm hg

PR:80 BPM

RR: 15 cpm

CVS:S1 and S2 heard ,no murmurs.

RS:BAE present,no additional sounds.

CNS: NFND

Daily routine:

Patient wakes up at 6 in the morning freshens up and has her breakfast at 7:30 and goes to class at 8 and at 1 she has her lunch and by 2 goes back to class .

After class she comes back at 4 in the evng and has tea and snacks and does her personal work and has dinner at 8 pm and studies till 10 and goes to bed by 11.

Treatment:

Symptomatic treatment.

Plenty of oral fluids.

[7/20, 3:00 PM] Shareena Kims: Op no : 20230735658

A 18 year old male came to OPD with c/o low grade fever since morning 4 am 

C/o vomitings ( 6 episodes)

 Contained food particles .

C/o body pains and generalised weakness.

N/k/c of HTN, DM, asthma, epilepsy, TB, seizures.

On examination:

Patient is c/c/c 

Temperature: 99.2F

PR:85 BPM

BP: 100/70 mmhg

CVS:S1 and S2 heard ,no murmurs.

CNS: NAD

RS: BAE +,NVBS +

P/A: soft,non tender

Daily routine:

Patient is a student and stays in hospital,wakes up at 6 am has breakfast at 7 and goes to college by 8 pm and comes back to hostel for lunch and goes back to class by 2 pm and by 5 he comes back to hostel and has dinner at 8pm and goes to bed by 10 pm 

Treatment:

Symptomatic treatment

Plenty of oral fluids

ORS.

[7/20, 3:28 PM] +91 91007 16817: Op no. 20230727118

A 48 year old male farmer by occupation came with a complaint of Giddiness since 1 year more during early morning 

Aggravates while driving bike 

N/h/o hearing loss,tinitus.

N/h/o fever,cough, vomiting,loose stools,pain abdomen 

N/k/c/o of diabetes, hypertension, tuberculosis, epilepsy, thyroid disorders, or asthma.

Dix-Hallpike maneuver - Negative 

O/E:- 

Pt. Is C/C/C

BP:-  supine:120/80 mmHg

      standing:120/80 mmHg 

PR:-  72 bpm.

RR:18/min

CVS:- S1 and S2 heard, no murmurs .  

RS:- BAE ,no additional sounds. 

P/A:-  soft and not tender.

CNS:- NFND

Daily routine- 

He is a farmer by occupation.He wakes up at 5am has breakfast at 7:30AM and goes to farm. He eats lunch at around 12:30pm and takes nap for an hour resumes his daily work. He has dinner at 7:30 and sleeps by 10PM. His routine has not been affected by his illness although he is more tired now.

Advice: symptomatic treatment.

[7/20, 4:01 PM] +91 91007 16817: OP NO. 20210519368

17 year old female came to the opd with 

C/o fever since 4 days -high grade associated with chills and rigors relieved with medication 

C/o Burning micturition since 2days

H/o loose stools 2days ago

Cough -dry ,no diurnal variation 

N/h/o vomitings, Giddiness,cold 

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

On examination:

Temperature: febrile - 99.3F

PR: 98bpm

BP: 100/60mmHg

RR: 18cpm

CVS: S1 S2+, no murmurs

CNS: NAD

RS:  BAE+ NVBS+

P/A: soft , non tender

Daily routine:  

Patient occupation : Student (stays at hostel)

The patient follows a consistent daily routine:

- Wakes up at 6:00 am

- Freshens up and has breakfast at 7:30 am

- Attends classes from 8:00 am to 1:00 pm

- Lunch at 1:00 pm

- Attends classes again from 2:00 pm to 4:00 pm

- Freshens up and has snacks at 4:30 pm

- Takes a nap from 5:00 pm to 6:00 pm

- Dinner at 7:00 pm

- Engages in studies or personal activities from 7:30 pm to 9:00 pm

- Sleeps by 10:00 pm.

Advice : 

Symptomatic treatment.

21july 2023

[7/21, 9:50 AM] +91 98486 60281: OP NO:20230732941

A 19 year old female came to opd with complaint of loose stools 15 times/day since yesterday, watery consistency,low quantity,non foul smelling with abdominal pain,nausea,high grade fever with chills and rigors,dry mouth present

No history of consumption of outside food,vomitings,sore throat,cough,cold,burning micturition

N/k/c/o diabetes,hypertension, tuberculosis, epilepsy,thyroid or asthma

Pt is C/C/C

BP:110/70

PR:80

RR:18

CVS:S1,S2+ , no murmurs

RS:BAE,NVBS +

CNS:NFND

P/A:soft,tenderness present in epigastric region

Daily routine:

She is a nursing student.she wakes up at 6:30am,have breakfast at 7:30,goes to college at 8am.She has her lunch at 12:30pm,goes back to college at 1:30pm,come back to hostel at 4pm,have dinner at 7:30pm,she ll go to study hours from 8 to 10pm and sleeps at 10:30pm.

Advice:

Take more oral fluids

ORS

Symptomatic treatment

[7/21, 10:15 AM] Sai Kiran Chanda Kims: OP NO:2023073381

A 50 year old female came to opd with complaint of neck pain radiating to shoulder since 2 days which aggravated on lifting heavy weights and relieved on rest .

No history of fever, tingling sensation of Upper limb.

N/k/c/o diabetes,hypertension, tuberculosis, epilepsy,thyroid or asthma

Pt is C/C/C

BP:130/80

PR:70bpm

RR:16

CVS:S1,S2+ , no murmurs

RS:BAE,NVBS +

CNS:NFND

P/A:soft,non -tender.

Daily routine:

She is a Daily wage worker by occupation, works at a construction site and used to lift sand and bricks and now she just waters the building being constructed with a hose pipe .she wakes up at 6:30am,have breakfast at 7:30,goes to work at 8am.She has her lunch at 12:30pm, continues the work after lunch till 6 pm .she goes home by 7pm and have dinner at 8 pm and sleeps at 10 pm .Her sleep is disturbed due to pain .

Advice:

Symptomatic treatment

Advice rest

[7/21, 10:28 AM] +91 98486 60281: OP No:20230732946

A 37 year old female came to opd with complaints of dragging type pain of upper limb and lower limb of right side since 3 days

Neck pain since 3 days

Cold and fever-low grade,on n off since 10 days

Swelling in left ear + and pain in left groin present .

No complaints of burning micturition, tingling,burning sensation of limbs.

K/C/O DM-2(MODY-3) since 17 years on OHD

Using T.Metformin 500/3 /PO/BD

T.Voglibose 0.2mg /PO/OD

K/C/O left emphysematous pyelonephritis

Pt is c/c/c

BP:120/80mmhg

PR:70bpm

RR:16cpm

CVS:S1,S2 heard,no murmurs

CNS:NFND

P/A:soft,non tender

 

Daily routine:

She is agricultural labourer,works in paddy fields.Wakes up at 4am,does household works and have breakfast at 7am,goes to work at 8am,have lunch at 1pm,come back from work at 6pm,cooks for family,have dinner at 8:30pm,watches television and sleeps at 11pm.

[7/21, 11:43 AM] Sai Kiran Chanda Kims: Op no. 20210120186

A 70 year old male farmer by occupation came with a complaint of giddiness on standing up from sleeping position since 15 days.

Tinnitus present  bilateral since 1 year .

C/O chest pain pricking type, on and off  since 1 week .

H/O trauma with bottle over the chest.

N/h/o hearing loss,fall.

N/h/O burning micturition , decreased urine output .

No orthostatic hypotension.

N/K/C/O diabetes, hypertension, tuberculosis, epilepsy, thyroid disorders, or asthma.

O/E:- 

Pt. Is C/C/C

BP:-  140/90mmHg 

PR:-  76 bpm.

RR:16/min

CVS:- S1 and S2 heard, no murmurs .  

RS:- BAE ,no additional sounds. 

P/A:-  soft and not tender.

CNS:- NFND

Daily routine- 

He wakes up at 6am and has breakfast at 8 am. He goes to his farm land  after breakfast. In the farm he does minor works . Has lunch at 2PM. He resumes work after lunch and has dinner at 9PM and sleeps by 10PM.

Advice: symptomatic treatment .

[7/21, 12:22 PM] Shubankar: OP number: 20230733938

A 21 year old Male came to opd with complaints of loose stools since 1 day (4 episodes a day)

Semisolid consistency, low quantity, non foul smelling 

H/o consumption of outside food

No complaints of abdominal pain, malena, fever, vomitings, burning micturition,

N/K/C/O HTN  DM ASTHMA TB EPILEPSY CVD

On Examination: 

Patient is conscious,coherent,cooperative

No pallor,icterus,cyanosis,clubbing,lymphadenopathy

Temperature: Afebrile

PR:76bpm

BP:110/70mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

Occupation:Student. 

Patient wakes up at 6am, has breakfast at

7:30am and goes to college at 8am am and has lunch at 1pm, comes back home at 5pm and studies for 2 hours and has dinner at 8 pm and goes to sleep at 10pm.

Advise:

Avoid outside food 

Drink plenty of oral fluids

Regular exercise

[7/21, 12:41 PM] +91 6309 842 248: Op-20230733439

A 30 year old male patient came to ops with 

C/o 

1)  high stepping gait since 1 month which is insidious in onset and initially developed weakness of lower limb and then used ?medication 2 weeks and then resolved 

2) bilateral lower limb tingling sensation positive 

Past history - he is not a known case of Dm, HTN,asthma , epilepsy,CVA,CVD

H/o alcohol consumption before but stopped 1 month back 

On examination - patient is conscious, coherent,cooperative 

Temp-afebrile 

PR- 94bpm

BP-90/60

RR-16

No pallor ,icterus,cyanosis,clubbing and lymphadenopathy.

CVS-S1 S2 heard , no murmurs heard 

Rs- BAE + ,NVBS heard 

P/a- soft, non tender, bowel sounds positive 

CNS- 

Power - right.    Left. 

UL.          4/5.      4/5 

LL.      

       Proximal- 4/5.    4/5 

       Distal     -3/5.     3/5

TONE - 

UL.              N.          N 

LL.               N.          N

REFLEXES      RIGHT    LEFT 

B.                       -ve.        -ve 

T.                       -ve.         -ve 

S.                       -ve.         -ve 

K.                      -ve.          -ve 

A.                      -ve.          -ve 

P.                        F.               F

No nystagmus 

Rombergs-ve

Daily routine - 

Patient occupation- driver and farmer 

Patient wakes up at 6:30 am and have tea and goes to field work and then comes to home at 8:30am and eats breakfast and goes to work ( driving) and at 1 o clock he eats lunch at home and goes back to work (driving) and then he comes home at 5or 6 and have snacks (tea and biscuits) and goes for field work and have alcohol(90ml) and then at 9 o clock he goes to home and sleeps at 9:30 pm 

After symptoms

He occasionally goes to driving work and takes care of field work

Dr.HARIPRIYA (PGY2)

DR.GOVARDINI (PGY1)

Dr.ZAIN (SR)

[7/21, 12:58 PM] Shubankar: OP number: 20210212974

A 32 year old Female came to opd with complaints of Generalised weakness, Headache, Giddiness since 10 days. 

Headache present in frontal region. 

Tenderness present in frontal sinus. 

H/o burning sensation of skin of upper limbs 

No complaints of fever vomitings loose stools chestpain cold cough shortness of breath palpitations 

K/C/O HTN since 6 months on medication T. Telmikind 20 mg

N/K/C/O DM ASTHMA TB EPILEPSY CVD CAD

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile

PR:86bpm

BP:140/100mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

Occupation:Housemaker 

Patient wakes up at 6am and does household chores and has breakfast at 9am. Then she prepares lunch and has lunch at 1pm then sleeps for one and half hour and does the remaining household chores and prepares dinner and has dinner at 9 pm and goes to sleep at 10pm.

Advise:

Avoid lifting heavyweights 

Regular exercise 

Adequate rest

[7/21, 1:06 PM] +91 6309 842 248: Op: 20230734310

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- 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 (tailor )work and at 10 o clock he goes to home and eats dinner and then he sleeps at 11 o clock 

And after the palpitation symptoms occurred he said he will drink water and then relaxes for a bit and then continues his normal work

[7/21, 2:33 PM] Prashanth Kims 2: 20230721421

A 55 yrs old male came with complaints of headache and neck pain radiating to left arm for 1 month 

Giddiness for  1 month

Patient was apparently asymptomatic 1 month back. One day after lifting some heavy log of wood suddenly, he developed this neck pain and headache which was continuous and persistent since then, No photophobia , no phonophobia , not associated with nausea and vomiting, no fever .Giddiness was insidious and was aggravated on making head movements.

H/o Snake bite 1 year back and was admittted for the same and treated ( doesnt know the type of snake )

Patient is a Daily wage labourer ( works in agriculture land)

Alcohol and smoking -stopped 1 yr back after snake bite incident ( on advise of doctors)

K/c/o HTN for  2yrs and on medication 

Appetite normal

Sleep disturbed due to pain 

Bowel and bladder regular

Mixed diet

General Examination 

Patient is conscious , coherent and cooperative

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

Vitals

Afebrile 

BP 140/ 80 mm Hg

PR 78 bpm

RR 16 cpm

Systemic examination

Cvs -S1 and S2 heard , No murmers

RS - BAE +  and NVBS heard

Per abdomen - soft and non tender

CNS

Sensory system intact 

Tone - normal 

Reflexes- normal

Power -normal

No autonomic dysfunction

No signs of cerebellar dysfunction

[7/21, 2:46 PM] Prashanth Kims 2: 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, no murmers

CNS: NFND

RS :BAE , NVBS

Per abdomen  Soft , Non tender

[7/21, 3:21 PM] Prashanth Kims 2: OP number:20230424476

A 51 year old Male came to opd with complaints of pain in the left chest localised to a point ,non radiating since 2 days 

H/o Burning sensation of soles since 2 months 

No complaints of palpitations, shortness of breath , excessive sweating , pain abdomen ,weight loss, loss of appetite. 

N/K/C/O HTN  DM ASTHMA TB EPILEPSY CVD

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile

PR:68bpm

BP:100/60mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

Occupation:works at a general store. 

Patient wakes up at 6am, has breakfast at 6:30am and goes to work at 8am am has lunch at 1pm, comes back home at 5pm have dinner at 8 pm and goes to sleep at 10pm. Since last 2 months has difficulty while working due to burning sensation of soles. 

Advise:

Regular exercise 

Diet change 

Adequate hydration

22 july 2023

[7/22, 9:59 AM] +91 93819 75404: Op no -20230734812

A 60 yr old Patient came to opd with

C/o-B/L pedal edema since 3days

Burning micturition since 3 days now subsided 

No seasonal/diurnal variation 

No orthopnea

No Giddiness

N/H/o palpitations 

N/H/o - fever ,cough

N/H/O- decreased urine output

Chronic smoker since 40 yr(chutta 3-4/day)

Not a k/c/o-DM ,HTN,CAD,CVA,seizures

 Examination: Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 78 bpm

Bp: 110/70 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(occasionally)and take restfor some time and dinner at 8 pm and go bed at 10 pm

Patient stopped going for farming since 2 yr due to easily getting fatigue 

10 days back he had bodyaches , nausea and decreased appatite for which he went to local hospital after using medicine he felt better then 3 days back he developed pedal edema and SOB

Dr.keerthi( PGY2)

Dr.nithin(PG1)

[7/22, 10:30 AM] +91 93819 75404: Op no -20230735215

A 58yr old  Patient came to opd with C/o pain in

Epigastric region Burning type since 1 yr

Non radiating ,aggrevated on talking and intake of spicy food,non veg

No h/o palpitations, no sweating

No h/o shortness of breath 

Indigestion since 6 months

Alcohol intake since 2 yrs(weekly twice)

Not a k/c/o-DM ,HTN,CAD,CVA,seizures

 Examination: Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 90 bpm

Bp: 110/80 mm Hg

Rr - 20cpm

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   does all feild work,have some milk at 9 Am and lunch at 1pm and take rest for some time and dinner at 8 pm and go bed at 10 pm

3 months back he c/o right loin pain and was diagnosed with renal calculi

Advice 

Avoid spicy food and non veg

Intake of plenty if water

Symptomatic treatment

Dr.keerthi PG2

Dr. Nithin PG1

[7/22, 10:36 AM] +91 93819 75404: His son is supporting him financially sir and he didn't get any investigation done till now for fatigue

[7/22, 10:37 AM] Rakesh Biswas Sir: But he left his job? Maybe that was anyway his retirement plan?

[7/22, 10:37 AM] +91 93819 75404: Yes sir

[7/22, 11:29 AM] +91 93819 75404: Op no -20230735785

A 20yr old  female Patient came to opd with C/o weight loss upto 5 kgs in 2 months(before 47 kgs after 2 months 42 kgs)

Giddiness and dry mouth since 1 month

Soreness of mouth since 1 month

Oral ulcers since 3 months (on and off)

No H/o fever ,loss motions

No h/o burning micturition 

No h/o of cough,constipation 

No addictions 

Not a k/c/o-DM ,HTN,CAD,CVA,seizures

 Examination: Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 90 bpm

Bp: 110/70 mm Hg

Rr - 18cpm

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 is a nursing student 

Patient wake up 7 am  ,have some milk and breakfast at 7:40 Am and goes to clg and have lunch at 1pm and come back to hostel by 4  and dinner at 8 pm and go bed at 12 pm

Dr.keerthi PGY2 

Dr.nithin PGY1

[7/22, 12:03 PM] +91 93819 75404: Op no -20230735822

A 51 yr old  male Patient came to opd with C/o easy fatiguability since 3-4 yrs

Generalised weakness present

K/c/o- migrane. Headache (occipital region) occasionally since 1 yr

Vomiting and Giddiness 

No addictions 

Not a k/c/o-DM ,HTN,CAD,CVA,seizures

 Examination: Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 81bpm

Bp: 110/70 mm Hg

Rr - 18cpm

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 is a welder by occupation 

Patient wake up 7 am  ,have some tea and breakfast at 9:30Am and goes to work and have lunch at 1pm and come home 5  and some tea and dinner at 8 pm and go bed at 9:30pm

From 3 to 4 yr he is c/o vomiting (2 to 3 episodes per week),blurring of vision,headache and was diagnosed migrane 1 yr back

He is unable to do work .he is taking multiple breaks while working (easily getting fatigue )

Dr.keerthi PGY2 

Dr.nithin PGY1

[7/22, 12:52 PM] +91 99081 89365: Op no -20230709589

A 60 yr old female Patient came to opd with C/o vertigo since 3days 

Blurring of vision, abdominal discomfort,nausea, headache,neck pain.

No C/O of fever ,sob, constipation 

K/c/o- CAD on medication.

HTN on medication since 5 yrs (Telma H)

No addictions 

Not a k/c/o-DM ,CVA,seizures, Thyroid disorders

 Examination: Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 83 bpm

Bp: 120/80 mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard,No murmurs

Apex beat - localised in 5th ICS

Rs: BAE+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

Daily routine-

Patient is daily labourer by occupation 

Patient wake up 7 am  ,have some tea and breakfast at 9:30Am and goes to work and have lunch in the field at 1pm and come home 5  and takes some rest, completes her House work by 7 and cooks food  and have  dinner at 8 pm and go bed at 10.00pm

From past 3 days patient was unable to do her daily routine with vertigo as her c/o along with it blurring of vision, abdominal discomfort .

Dr.keerthi PGY2 

Dr.nithin PGY1

[7/22, 2:56 PM] +91 93819 75404: Op no -20230735756

A 32yr old  female Patient came to opd with C/o Generalized body pains since 15 days

Tingling sensation +

Pain abdomen since 15 days.burning type of pain in Epigastric region

Burning micturition +,LBA+

no H/o vomiting, SOB,chest pain

C/o B/L knee joint pain

No addictions 

Not a k/c/o-DM ,HTN,CAD,CVA,seizures

 Examination: Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82bpm

Bp: 110/70 mm Hg

Rr - 18cpm

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 is a farmer by occupation 

Patient wake up 5:30 am  ,have some tea and does all house work and have breakfast at 7:30Am and goes to field and have lunch at 1pm and come home 5   and dinner at 8 pm and go bed at 11:30pm

Dr.keerthi PGY2 

Dr.nithin PGY1

[7/22, 3:23 PM] Rakesh Biswas Sir: What is her weight? Is the weight loss more than 10% of her body weight?

[7/22, 3:28 PM] +91 93819 75404: Her wt right now is 42 kgs .2 months back 47kgs .yes sir

[7/22, 3:43 PM] Rakesh Biswas Sir: How would you estimate her body fat and muscle mass? 

Mid arm circumference? Skin fold thickness?

24 july 2023

[7/24, 10:41 AM] Gouri Reddy 2k18 Kims: OP no : 20230737050

A 62 year old female came with C/o :

Bilateral pedal edema since 3 days which is of pitting type 

Reduced appetite since one week 

No h/o shortness of breath 

No h/o reduced micturition

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

O/E: 

Pt is c/c/c 

Afebrile 

PR- 76 bpm

BP- 130/ 80 mmHg 

 RR- 16cpm 

CVS: S1,S2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS: NFND

Daily routine : 

Patient is a homemaker. 

She wakes up by 6 am and has breakfast by 8 am. She does her daily chores for sometime and has lunch by 1 pm. She rests in the afternoon for a while. At around 4 pm, she has a cup of tea. By 8 pm, she has her dinner and goes to bed by 10 pm. 

Seen by 

Dr. Pavani (PGY2)

Dr. Nitin (PGY1)

[7/24, 10:57 AM] Spoorthy Kims: Op no -20210305856

A 27yr old male patient, a PG student came to opd with c/o headache since 2 months

C/O fever and generalized body pains since 5 days

C/O photophobia

No H/O nausea, vomitings, cold, cough. 

Headache is on and off since 2 months and usually persists for 3-4 days. 

No addictions 

Not a k/c/o -DM ,HTN,CAD,CVA,seizures, asthma

 Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 82bpm

Bp: 120/70 mm Hg

Rr - 18cpm

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 is a student by occupation. 

Patient wakes up 5:30 am , studies for some time and has breakfast at 9:00am and goes to library to study and has lunch at 1pm and then continues with his study and then has his dinner at 9 pm and goes bed at 12am.

Currently his sleep time has increased  and study time has decreased due to his headache. 

Dr.Pavani PGY2 

Dr.Nithin PGY1

[7/24, 11:28 AM] Spoorthy Kims: Op no -20210420270

A 28yr old female patient came to opd with 

C/O giddiness since 1 month 

Associated with headache (occipital region) 

H/O nausea and vomiting occasionally at the time of headache. 

H/O photophobia

H/O phonophobia

C/O palpitations +

No h/o fever, trauma. 

No C/O weight gain/loss, constipation/loose stools

 Patient also complains of anger issues and memory dusturbances. 

  

No addictions 

Patient has migraine since her schooling and uses T.Grenil for her migraine attacks. 

Not a k/c/o -DM ,HTN,CAD,CVA,seizures, asthma

 Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 84bpm

Bp: 110/70 mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard,No murmurs

Rs: BLAE+, NVBS heard

P/a:  soft, non tender

CNS - NFAD

 Daily routine-

Patient has completed her btech and currently in search of a job.She is married. 

Patient wakes up at 6:30 am , prepares breakfast, does some household work, have breakfast at 10:00am and studies for sometime Then she have her lunch at 2pm and then taken an afternoon nap for about an hour and then have tea in the evening,prepares dinner and eats her dinner at 9 pm and goes bed at 11pm.

Dr.Pavani PGY2 

Dr.Nithin PGY1

[7/24, 12:10 PM] Spoorthy Kims: Op no -20210211030

A 50yr old male patient came to opd with 

H/O an episode of involuntary movements of hands and legs lasting for 5-10minutes yesterday. 

Episode was preceeded by aura

Post icteral confusion+

No uprolling of eyeballs

No frothing from mouth

No involuntary micturition/defeacation

C/O bodypains after the episode

Pt is a K/C/O epilepsy since 3years

On regular medication T. Phenytoin 100mg  1----x----2

Pt informs that he has not been on medication for the past 3 days. 

H/O last seizure attack 3 years back for which he was hospitalized and was  started on treatment. 

Not a k/c/o -DM ,HTN,CAD,CVA, asthma. 

 Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 84bpm

Bp: 130/70 mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard,No murmurs

Rs: BLAE+, NVBS heard

P/a:  soft, non tender

CNS - NFAD

 Daily routine-

Patient works in a hostel. 

He usually wakes up at 6:00 am , gets ready and go to hostel by 7:00am, has breakfast at 9:00am in the hostel itself and has lunch at 1pm . He usually comes back home at 6:00pm in the evening and have dinner at 9 pm and goes bed at 11pm.

Dr.Pavani PGY2 

Dr.Nithin PGY1

[7/24, 12:46 PM] Gouri Reddy 2k18 Kims: OP no : 20210511847 

A 45 year old female came with C/o :

Shoulder pain since 1 year 

Body pains since 1 year

Burning sensation of both the eyes +

Polyuria +

K/C/o DM since 9 months and is on Tab Metformin 500 mg PO/OD

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

O/E: 

Pt is c/c/c 

Afebrile 

PR- 84 bpm

BP- 110/ 80 mmHg 

 RR- 16cpm 

CVS: S1,S2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS: NFND

Seen by 

Dr. Pavani (PGY2)

Dr. Nitin (PGY1)

[7/24, 3:06 PM] Gouri Reddy 2k18 Kims: OP no : 20230738650 

A 37 year old female came with C/o :

Abdominal distension since 2 months

Shortness of breath (grade 2) since 2 months 

Constipation since 2 months 

H/o belching 2 months back. Relieved on taking medication 

H/o syncope 1 month back due to low blood pressure 

No h/o nausea , vomiting

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

Daily routine : 

Patient is a shopkeeper by occupation 

She wakes up at 6 am, does her home chores and has breakfast by 8 am. She goes to work by 9 am. She has lunch by 1 pm. She has a cup of coffee at 4 pm. She finishes her work by 7 pm and goes home by 8 pm. Has her dinner 9 pm and goes to bed by 11 pm 

O/E: 

Pt is c/c/c 

Afebrile 

PR- 82 bpm

BP- 130 / 80 mmHg 

 RR- 18 cpm  

CVS: S1,S2 heard ,no Murmurs, 

RS:BAE+ ,no added sounds ,NVBS,  

P/A: soft, non tender

CNS: NFND

Seen by 

Dr. Pavani (PGY2)

Dr. Nitin (PGY1)

[7/24, 3:18 PM] Spoorthy Kims: Op no -20230735818

A 51yr old male patient came to opd with 

C/O easy fatiguability since 3-4 yrs

C/O generalized weakness +

 K/C/O migraine since 1 yr

He experiences headache (occipital region) occasionally 

Pt also complains of vomitings and giddiness

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

 Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 81bpm

Bp: 110/70 mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

 Daily routine-

Pt works in a brass manufacturing company. 

He usually wakes up around 6am in the morning, have breakfast at 8am then goes for work. He has his lunch around 1:00pm and then gets back to work. He gets back home at 5:00pm ,  watch television, spends time with family then have his dinner at 9:00pm. After dinner he goes for a walk then sleep at 10:30pm

Initially he used to work for 9 hrs. But now a days he is unable to work for more than 3 hrs. He gets easily fatigued. 

Dr.Pavani PGY2 

Dr.Nithin PGY1

[7/24, 3:35 PM] Spoorthy Kims: Op no -20210511847

A 47yr old female patient came to opd with 

C/O shoulder pain since 1 yr

C/O generalised body pains since 1 yr

Patient also complains of burning sensation of both eyes

C/O polyphagia+

C/O polyuria +

K/C/O DM since 9 months and on T.Metformin 500mg PO/OD

Not a k/c/o -HTN,CAD,CVA, asthma, epilepsy

 Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 84bpm

Bp: 160/100 mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

 Daily routine-

Pt works as a teacher in a private school

She usually wakes up at 5:30am in the morning, does household work, prepares breakfast and then goes for work at 8:00am. She have her lunch at 12:30pm . She gets back home at 4:00pm , takes rest for sometime, drinks tea in the evening, does some household work and then have her dinner at 9:00pm. She sleeps at 10:30pm.

Because of her current complain of shoulder pain she experiences difficulty while writing notes on the board. 

Dr.Pavani PGY2 

Dr.Nithin PGY1

[7/24, 3:42 PM] Rakesh Biswas Sir: Since when is she teaching and using her shoulders to write on the board? One year?

[7/24, 3:48 PM] Spoorthy Kims: She is teaching since 15 years and writing on the board since then sir.

[7/24, 4:10 PM] Rakesh Biswas Sir: What may have changed in her activities especially around her shoulder joint muscles one year back?

25 july 2023

[7/25, 9:58 AM] +380 68 613 9267: Op no -20230738886

A 34yr old female patient came to opd with 

C/O generalised body pains, tingling sensation in bilateral  upper and lower limbs since 10days associated with giddiness and intermittent chest pain

K/c/o Hypothyroidism, on Tab. Thyronorm 75mg

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

 Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 84bpm

Bp: 110/80 mm Hg

Rr - 18cpm

No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy, polyuria, polydypsia, weightgain or weightloss, syncopial attacks, blackouts, SOB, consitipation

Complains of hairloss. 

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

 Daily routine-

Pt used to work as an agricultural laborur 10years ago, but now she stopped working, she wakes up at 5 am in the morning, does her household work and has breakfast by 9am later sits in the shop that the family owns, has her lunch by 1pm and goes back to taking care of the shop until 8 pm she has her dinner by 9pm and goes to bed by 10pm. 

Due to her current complains there is no change in her daily routine 

Dr. Narsimha reddy PGY2 

Dr.Govardhini PGY1

[7/25, 10:05 AM] Rakesh Biswas Sir: Worked 10 years ago but now she stopped? 

When did she stop? 10 years ago or now? Do you mean she started 10 years back and stopped now?

[7/25, 10:06 AM] Rakesh Biswas Sir: Hypothyroidism since? On 75 since?

[7/25, 10:17 AM] +380 68 613 9267: Sir she stopped 10years ago after she gave birth to her child, since then she's just been doing her household work and looking after her daughter and runs the shop

[7/25, 10:18 AM] +380 68 613 9267: Op no -20230739277

A 33 old man who works as a tractor driver came to the opd with complains of swelling in bilateral lower limbs since 20days and also watering of eyes, facial puffiness  since 3days 

Bilateral Lower limb swelling gradually progressed upto knees since the last 20days

Not a k/c/o -HTN,CAD,CVA, DM, thyroid problems, asthma, epilepsy

 Examination: Patient is conscious, coherent, cooperative 

Alcohol habit:  Patient started drinking since the age 20 and drinks about 90-120ml daily ever since

Temp: Afebrile

Pr: 92bpm

Bp: 110/70 mm Hg

Rr - 16 cpm

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

Cvs:-S S2 heard, no added sounds

Rs:-BAE+, NVBS +

P/a: - soft, non tender

CNS: - NFD

JVP :- NOT raised 

 Daily routine-

Pt works as a tractor driver for the last 12 years, waked up by 5 Am, freshens up has his breakfast by 9Am and goes to drive his tractor, works until 1Pm and has his lunch and gets back to work until 7in the evening after which he  gets back home has his dinner by 9 pm and goes to bed by 10pm. His current complains haven't effected his daily routine 

Dr. Narsimha reddy PGY2 

Dr.Govardhini PGY1

[7/25, 10:23 AM] +380 68 613 9267: Since 4"years sir

[7/25, 10:31 AM] Mrunalika Kims 2k18: Op no -20210225513

A 27 yr old female patient came to opd with 

C/O headache since 1 month 

5 to 6 episodes in a day, each episode lasting for 15 min

C/O retrosternal burning sensation since 20 days

Aggrevated after eating food

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

Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 84bpm

Bp: 110/80mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

 Daily routine-

Pt works as a carpenter.

She usually wakes up at 5:30am in the morning, does household work, prepares breakfast and have breakfast at 8:30am and then starts work at 9:00am along with her husband at home. She have her lunch at 1:00 pm and continues to work until 9pm, then have her dinner at 9:00pm. She sleeps at 10pm

Because of her current complain, there is no change in her routine 

Dr. Narasimha Reddy PGY2

Dr. Govardhini PGY1

[7/25, 10:45 AM] Mrunalika Kims 2k18: Op no -20230738891

A 65 yr old female patient came to opd with 

C/O abdominal pain since 10days

Associated with abdominal bloating, belching, abdominal fullness 

C/O chest pain since 10 days

Pricking type, non radiating, more on left side

Not associated with SOB, cough, cold, palpitations 

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

Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 80bpm

Bp: 120/80mm Hg

Rr - 17cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

 Daily routine-

Pt works as a daily labourer in cotton fields 

She usually wakes up at 5am in the morning, does household work, prepares breakfast and have breakfast at 8:30am, packs lunch and then goes to work at 9:00am at fields. She have her lunch at 1:00 pm at the field itself and continues to work until 5 pm, then comes back home, freshen up, cooks dinner and have it at 8:00pm. She sleeps at 9:30pm

Because of her current complain, there is no change in her routine 

Dr. Narasimha Reddy PGY2

Dr. Govardhini PGY1

[7/25, 10:45 AM] Mrunalika Kims 2k18: Op no -20230739332

A 46 yr old female patient came to opd with 

C/O cough since 2 weeks 

Dry cough, aggrevates during night time

No c/o fever, throat pain

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

Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 90bpm

Bp: 110/70mm Hg

Rr: 17cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

Daily routine-

Pt works as a daily labourer in fields

She usually wakes up at 5am in the morning, does household work by 7am prepares breakfast and packs it , then starts to go to workplace and have breakfast there, and starts to work at 9:00am. She have her lunch at 1:00 pm and continues to work until 3.30and comes back home by 5pm , then have her dinner at 9:00pm. She sleeps at 10pm

Because of her current complain, she stopped going to work 

Dr. Narasimha Reddy PGY2

Dr. Govardhini PGY1

[7/25, 11:14 AM] Mrunalika Kims 2k18: Op no -20230739859

A 55 yr old male patient came to opd with 

C/O neck pain since 1 week

Aggravated on movements 

Relieved on sleeping

C/O headache since 2 days

Not associated with vomitings, photophobia, phonophobia

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

H/o spine surgery 6 months back

Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 80bpm

Bp: 110/80mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

 Daily routine-

Pt used to work as a mason but stopped after spine surgery 6months ago as the surgeon advised rest

He usually wakes up at 6am in the morning, have breakfast at 9am and then usually stays at home. He have lunch at 1:00 pm on somedays and doesn’t eat on somedays andtakes rest and have dinner at 8pm. sleeps at 9pm

Because of his current complain, there is no change in his routine 

Dr. Narasimha Reddy PGY2

Dr. Govardhini PGY1

[7/25, 11:17 AM] +380 68 613 9267: Op no -20230738893

48year old woman came to the OPD with complains of lower backache and abdominal pain since 1month

Lower back ache radiating to left lower limb with tingling sensation. Dragging type of pain. 

No restriction of movements or weakness or swellling 

Patient complains of abdominal pain with bloating and belching 

No regurgitation, constipation, polyuria, polyphagia, polydipsia. 

Not a k/c/o -HTN,CAD,CVA, DM, thyroid problems, asthma, epilepsy

 Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 72 bpm

Bp: 120/80 mm Hg

Rr - 18 cpm

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

Cvs:-S1 S2 heard, no added sounds

Rs:-BAE+, NVBS +

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 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 haven't effected her daily routine 

Dr. Narsimha reddy PGY2 

Dr.Govardhini PGY1

[7/25, 11:35 AM] +380 68 613 9267: Op no -20230739856

30year old woman came to the OPD with complains of fever, cold and generalised body pains amd weakness since 1day 

Fever is low grade intermittent associated with chills and rigors relived by taking paracetamol 

Not a k/c/o -HTN,CAD,CVA, DM, thyroid problems, asthma, epilepsy

 Examination: Patient is conscious, coherent, cooperative 

Temp: 99.9°f

Pr: 76bpm

Bp: 90/60 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 a daily wage agricultural laborour for the last 10years , she wakes up at 5 am and does a few household chores and goes to work in fields by 7am and around 10am has her breakfast and works in the field until 1 pm after which she has her lunch by 1:30 and rests for 30mins after that works until 5pm in the field and  goes home cooks for the family and has dinner by 9pm and sleeps by 10:30pm. 

 The above mentioned complains haven't effected her daily routine

Dr. Narsimha reddy PGY2 

Dr.Govardhini PGY1

[7/25, 12:13 PM] +380 68 613 9267: Op no - 20210424004

A 42year old man came to the OPD with complains of on and off pain in b/l loin since  3years 

C/o pain in both feet which is heightened in the morning and gradually subsides on its own within 30-60 minutes. 

Drinking habits: 

Patient has been consuming alcohol since 10years around 3-4times a week upto 250ml every time. 

H/o burning micturition, increased frequency and urgency

Not a k/c/o -HTN,CAD,CVA, DM, thyroid problems, asthma, epilepsy

 Examination: Patient is conscious, coherent, cooperative 

Pr: 80 bpm

Bp: 110/70 mm Hg

Rr - 18 cpm

No signs of pallor, icterus, cyanosis,clubbing and lymphadenopathy., no pedal edema

Cvs:-S1 S2 heard, no added sounds

Rs:-BAE+, NVBS +

P/a: - soft, non tender

CNS: - NFD

 

 Daily routine-

Patient is a weaver by occupation has been working on handheld weaving machine from the last 20years he has a a irregular pattern of sleep cycles and irregular times of eating. If he has alcohol the previous night he tends to wake up  around 10 am skips breakfast works for 4hrs had lunch after that and rests for 2hrs after most of his meals. He works after that and most of his work compels him to be  standing. In the evening he finishes his work and has his dinner somewhere beteeen 10-11pm depending on the work. 

 The above mentioned complains seem to gradually effect his daily routine

Dr. Narsimha reddy PGY2 

Dr.Govardhini PGY1

[7/25, 12:26 PM] Shivani Reddy. S kims: Op no -20230739870

A 57 yr old male patient came to opd with 

C/O belching since 5 months

C/o regurgitation of food since 5 months

K/c/o HTN since 1 year and is on medication TAB AMLONG 5mg PO/OD

Not a k/c/o -DM, CAD,CVA, asthma, epilepsy

Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 96bpm

Bp: 130/80mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/A: soft, non tender

CNS - NFD

Daily routine

Pt used to work as a photographer in their own photo studio.

But stopped working since 5 years as they closed the studio as there are no profits

He usually wakes up at 6:30am in the morning, have breakfast at 8am on somedays or have his lunch at 12pm and takes rest, and then have his dinner at 9:00pm and sleeps at 9:30pm

Because of his current complain, there is no change in his routine 

Dr. Narasimha Reddy PGY2

Dr. Govardhini PGY1

[7/25, 2:46 PM] Shivani Reddy. S kims: Op no :20230739322

A 47 year old female came to opd with C/O of right sided facial pain radiating from preauricular area to eye since 6 days.

C/O ear pain on drinking water and on eating sweet.

No C/O  ear discharge or ear pain.

No H/O ptosis,lacrimation or fever.

  

N/K/C/O DM ,HTN,CAD ,epilepsy and TB .

On examination:

Bp:110/70mm hg

Pulse : 76 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She is an employee in an agricultural office .She wakes up at 6 am  completes her household chores by 9 am and has her breakfast at 10:30 am.She goes to her work at 11 am and in between her work she has her lunch at 1 pm.She comes back to home from her work by 6 pm, has her dinner at 8 pm and sleeps by 10 pm. 

Due to her pain she stopped going to her work since 6 days and  she stays at home and takes rest.

Advice : symptomatic treatment 

Dr Narsimha Reddy(pg y2)

Dr Govardhini ( pg y1)

[7/25, 3:07 PM] Shivani Reddy. S kims: Op no :20210506039

A 14 year old male came to opd with C/O of hands and legs pain since 5 days

C/O tingling sensation since 5days

C/O nausea and decreased apetite since 5 days

 

H/O low grade fever since 10 days which is relieved on medication.

No H/O vomitings or loose stools

  

N/K/C/O DM ,HTN,CAD ,epilepsy and TB .

On examination:

Bp:120/70mm hg

Pulse : 76 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

He is school going student who  wakes up at 6am and  has his breakfast at  7am and goes to his school at 8 am.He has his lunch at 12:30 pm and comes back to home at 3:30 from school, He has some snacks at 5:00 ,studies till 9 finishes his dinner by 9:30pm and

 sleeps by 10 pm. 

Due to his pain he stopped going to his school since 2 days .  

Advice : symptomatic treatment 

Dr Narsimha Reddy(pg y2)

Dr Govardhini ( pg y1)

[7/25, 3:40 PM] Shivani Reddy. S kims: Op no :20230739332

A 47 year old female came to opd with C/O of  high grade intermittent  fever since  associated with  chills and rigor since 15 days.

C/O cough,cold ,body pains and headache since 15 days

No H/O burning micturition.

 

  

N/K/C/O DM ,HTN,CAD ,epilepsy and TB .

On examination:

Bp:110/70mm hg

Pulse : 82 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She is a labourer  by occupation. She wakes up at 6 am  completes her household chores by 10 am and has her breakfast at 10:30 am.She goes to her work at 11 am and in between her work she has her lunch at 1 pm.She comes back to home from her work by 6 pm, has her dinner at 8 pm and sleeps by 10 pm. 

Due to her fever she stopped going to her work since 5 days and  she stays at home and takes rest.

Advice : symptomatic treatment 

Dr Narsimha Reddy(pg y2)

Dr Govardhini ( pg y1)

[7/25, 3:55 PM] Shivani Reddy. S kims: Op no :20210525363

A 22 year old female came to opd with C/O of low grade  fever not associated with chills and rigor since 3 days and giddiness  since 3 days

C/O weight gain and increased apetite

 

No H/O vomitings or loose stools or burning micturition

  

N/K/C/O DM ,HTN,CAD ,epilepsy and TB .

On examination:

Bp:120/70mm hg

Pulse : 68 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She is a  student who  wakes up at 4am and  has her  breakfast at  7am and goes to her college at 8 am.She has her lunch at 1pm and comes back to her hostel from college by 5pm,

has her snacks at 5:30 pm 

from  ,studies till 9pm finishes her dinner by 10:00pm and

sleeps by 12 pm. 

There is no change in her daily routine due to her symptoms.

Advice : symptomatic treatment 

Dr Narsimha Reddy(pg y2)

Dr Govardhini ( pg y1)

26 july 2023

[7/26, 10:09 AM] +91 83741 92025: Op no -20210410139

A 26 year old woman came to the OPD with complains of generalized weakness since 3 days and got her BP checked from RMP 

24/7-160/80 mmHg

25/7-140/80 mmHg 

26/7-140/80 mmHg 

C/o SOB since 2 to 3 days 

SOB at rest present for 1-2 mins,relieves spontaneously

No c/o chest pain, palpitations,pedal edema, decreased urine output

No c/o fever,cold,cough

Not a k/c/o -CAD,CVA, DM, thyroid problems, asthma, epilepsy

 Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

PR:64 bpm

Bp: 140/90 mm Hg

Rr - 18 cpm

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

Cvs:-S1 S2 heard, no murmurs 

Rs:-BAE+, NVBS +

P/a: - soft, non tender

CNS: - NFD

 

 Daily routine-

Patient is a house wife, she wakes up by 7 in the morning does all the household chores 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 haven't effected her daily routine.

Advice : symptomatic treatment 

Dr. Narsimha reddy PGY2 

Dr.Lohith Varma PGY1

[7/26, 10:11 AM] Rakesh Biswas Sir: What's your diagnosis?

What's the cause of her shortness of breath?

[7/26, 10:11 AM] Akshitha 2kims: Op no :20230740760

A 38 year old male came to opd with c/o pain in left upper and lower limb for 2days .pain is of dragging type , continuous and high grade fever with chills for 1day  which relieved  with medication

At that time bp recording was 190/90mm Hg 4days ago

Pt is on telmisartan 40mg,amlodipine 5mg,hydrochlorthiazide 12.5mg

Tab.Nifedipine 10mg Po/OD/8pm

K/C/O  HTN since 1year .on medication-Tab TELMISARTAN 40mg PO/OD

N/K/C/O DM ,TB,Asthma,epilepsy, CAD ,CVD

On examination:

Bp:140/80mm hg

Pulse : 78 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

He is a barber  who  wakes up at 4am and  has his breakfast at  7am and goes to salon at 8 am.He has his lunch at 1pm and goes  back to work at 2pm .He comes back home at 8pm  finishes his dinner by 9pm and

sleeps by 11pm. 

There is no change in his daily routine due to his symptoms.

Advice : symptomatic treatment 

Dr Narsimha Reddy(PG y2)

Dr Lohith varma( pg y1)

[7/26, 10:14 AM] +91 83741 92025: She might have diastolic dysfunction

[7/26, 10:22 AM] Rakesh Biswas Sir: That's not a diagnosis!

[7/26, 10:22 AM] Rakesh Biswas Sir: 26F what could be the etiology for her diastolic dysfunction!

[7/26, 10:23 AM] Rakesh Biswas Sir: Diagnosis?

[7/26, 10:29 AM] +91 83741 92025: Hypertension leading to left ventricular hypertrophy

[7/26, 10:31 AM] Rakesh Biswas Sir: Share her clinical images of abd obesity and biceps 

Make her PaJR 

Get her to buy an electronic instrument and monitor her BP 10 times at random intervals on a single day and share in her PaJR group

[7/26, 10:32 AM] Rakesh Biswas Sir: How do you confirm left ventriculo hypertrophy?

[7/26, 10:36 AM] +91 83741 92025: By ECG we can confirm sir

[7/26, 10:36 AM] Rakesh Biswas Sir: What's the sensitivity of Ecg to pick up left ventricular hypertrophy? Does normal Ecg rule it out?

[7/26, 10:48 AM] +91 83741 92025: Conclusion: ECG criteria for the diagnosis of LVH had a relatively low sensitivity, and high specificity. The accuracy was in the range of 0.71-0.80.

[7/26, 10:49 AM] +91 83741 92025: Op no -20210413317

43 year old woman came to the OPD with complains of 

SOB since 1 week which aggrevates on work ( like climbing steps) and relieved on taking rest.

No c/o chest pain, palpitations,pedal edema.

No c/o cough and cold 

Not a k/c/o -HTN,CAD,CVA, DM, thyroid problems, asthma, epilepsy

 Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 88 bpm

Bp: 130/80 mm Hg

Rr - 18 cpm

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

Cvs:-S1 S2 heard, no added sounds

Rs:-BAE+, NVBS +

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 and have  her lunch by 2pm and after that she  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 haven't effected her daily routine 

Advice: symptomatic treatment

Dr. Narsimha reddy PGY2 

Dr.lohith Varma PGY1

[7/26, 10:53 AM] Rakesh Biswas Sir: So if ecg can't pick up her left ventricular hypertrophy, what will?

[7/26, 10:53 AM] Rakesh Biswas Sir: Diagnosis? 

Diastolic dysfunction?

[7/26, 10:59 AM] Akshitha 2kims: Op no -20230741224

30year old woman came to the OPD with c/o burning sensation in the epigastrium since 10days aggrevated after food intake  after 15mins,continous in nature, relieves after 3 to 4hrs

No c/o bloating,belching

No c/o sob , chestpain,orthopnea , PND

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

 Examination: Patient is conscious, coherent, cooperative 

Temp: 99.9°f

Pr: 76bpm

Bp: 100/70 mm Hg

Cvs:-S1 S2 heard, no added sounds

Rs:-BAE+, NVBS +

P/a: - soft, non tender

CNS: - NFD

 

 Daily routine-

Patient is a a daily wage agricultural laborour . she wakes up at 5 am and does a few household chores and goes to work in fields by 7am and around 10am has her breakfast and works in the field until 1 pm after which she has her lunch by 1:30 and rests for 30mins after that works until 5pm in the field and  goes home cooks for the family and has dinner by 9pm and sleeps by 10:30pm. 

Affecting her daily routine and not going to work since 4days

 

Diagnosis-GERD

Dr. Narsimha reddy PGY2 

Dr.lohith varma PGY1

[7/26, 11:01 AM] Rakesh Biswas Sir: GERD affecting daily routine! 

Is she willing to be admitted?

[7/26, 11:02 AM] Akshitha 2kims: She is not willing to get admitted

[7/26, 11:04 AM] Rakesh Biswas Sir: Then something is wrong about the information! 

Perhaps her 4 days of not working has other reasons?

[7/26, 11:12 AM] +91 83741 92025: Op no -20230741231

A 45 year old woman came to the OPD with complains of :

Giddiness since 3 days which is continuous through out the day and not altered by positional variations and associated with headache in b/l parietal region,tinnitus present.

 k/c/o -HTN since 4 years and on Tab.Telma 20 mg po/od

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

 Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 88 bpm

Bp: 140/90 mm Hg on supine position

       :140/90 mmHg on standing position 

Rr - 18 cpm

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

Cvs:-S1 S2 heard, no added sounds

Rs:-BAE+, NVBS +

P/a: - soft, non tender

CNS: - NFD

 

 Daily routine-

Patient is a house wife, she wakes up by 8 in the morning does all the household chores and have  her lunch by 2pm and has her dinner by 8 pm and goes to bed by 10pm. The above mentioned complains haven't effected her daily routine 

Diagnosis: Benign paroxysmal positional vertigo

Dr. Narsimha reddy PGY2 

Dr.lohith Varma PGY1

[7/26, 11:49 AM] Akshitha 2kims: Op no -20230741286

45year old woman who runs hotel but stopped as there is decrease in customers since 1 month came  with c/o generalised body pains since 1week 

Decreased Sleep since 1week

Palpitations since 1week 

C/o increased urination since 1week 

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

 Examination: Patient is conscious, coherent, cooperative 

PR: 79bpm

Bp: 100/70 mm Hg

Cvs:-S1 S2 heard, no added sounds

Rs:-BAE+, NVBS +

P/a: - soft, non tender

CNS: - NFD

 

 Daily routine-

Patient runs a hotel.  she wakes up by 7am in the morning does all the household chores and goes to hotel by 8am and has her breakfast around 10am .she has her lunch at 1.30pm and comes back home by 8 pm ,finishes her dinner at 9pm goes to bed by 10.30pm. 

The above mentioned complains haven't effected her daily routine 

Advice -symptomatic treatment

 

Dr. Narsimha reddy PGY2 

Dr.lohith varma PGY1

[7/26, 12:06 PM] Akshitha 2kims: Op no :20230741323

A 55 year old male came to opd with c/o cough(productive)with mucoid sputum since 3days,continous in nature,no diurnal variation with cold.and complains of body pains 

No c/o fever ,burning micturition,loose stools,vomiting. 

K/C/O  HTN since 10years .on medication-Tab TELMISARTAN 40mg 

K/C/O DM II since 10 years on Tab Glimi M1 po/od

N/K/C/O  CAD ,CVD, Asthma ,TB

On examination:

Bp:110/80mm hg

Pulse : 78 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

He works as police officer who  wakes up at 4am  and goes to duty at 7am and has his breakfast at  9am.He has his lunch at 2pm and goes  back to work at 3pm .He comes back home at 8pm  finishes his dinner by 9pm and sleeps by 11pm. 

There is no change in his daily routine due to his symptoms.

Advice : symptomatic treatment 

Dr Narsimha Reddy(pg y2)

Dr lohith varma( pg y1)

[7/26, 2:49 PM] +91 76758 70869: Op no: 20230742293

A 56yr old female came to opd with

 c/o  pain in the epigastric region which is Non radiating since 5 days

On examination 

Pt is conscious coherent and cooperative

Temp Afebrile

Bp 120/ 70 mmhg 

PR 90bpm

CVS :S1 S2 +

CNS: NAD

RS :BAE+,

P/A: soft,non tender

 Daily routine - she is a housewife, she wakes up at 6am,does household work , and has her breakfast at 9am and  she has lunch at  1pm and dinner at 7pm and she goes to sleep around 10pm

There is no change in her daily routine

Advice

Avoid spicy foods 

Symptomatic management

Dr.Zain (SR)

Dr.Narasimha (pgy2)

Dr.Lohith(pgy1)

[7/26, 3:58 PM] +91 76758 70869: Op no. 20230718314

A 36year old female came to the opd with the complains of Right sided Loin pain since 2 years radiating to Right lower limb

On examination:

Patient is concious, coherent and

cooperative. 

VITALS

Temperature: Afebrile

PR: 84bpm

BP: 130/70 mmHg

SYSTEMIC EXAMINATION :

P/A: soft , non-tender

CVS: S1 S2+, no murmurs

CNS: NAD

RS:  BAE+ NVBS+

DAILY ROUTINE: 

She is a Agricultural Labourer by occupation 

The patient wakes up at 6am gets freshened up and does her daily activities and prepares breakfast at 7.30am and have it by 8am.She goes for work. She has lunch at 1:00pm  and comes to home around 4pm. She has dinner at 8:00pm and sleeps at 10pm.

No changes in her daily routine due to above complaints

Advice:

Advice to drink lot of water

Symptomatic treatment.

Dr. Zain (SR)

Dr.Narasimha(pgy2)

Dr. Lohith(pgy1)

[7/26, 4:12 PM] Rakesh Biswas Sir: Number of customers in a day two months back and one month back and yesterday?

[7/26, 4:13 PM] Rakesh Biswas Sir: Diagnosis?

27 july 2023

[7/27, 10:14 AM] Samhita Kims: OP number:20230742994

A 35 year old male came to opd with complaints of neck pain since 5 days.

No h/o radiation of pain.

No h/o difficulty in neck movement, headache, giddiness.

No h/o fall. 

Not a K/C/O DM, HTN, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:86 bpm

BP:120/80mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

He is a painter by profession. He gets up at 5am, goes to farm ,comes home by 8 am , has breakfast at 9 am and goes to work. He travels by bike to work which is about 30km away. 

He has lunch at 1pm.He goes back home around 7:30pm. He has dinner at 8 pm and goes to bed by 9pm.

No recent changes in the daily routine have been reported.

Advise:

Rest to neck.

Symptomatic Treatment. 

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 10:27 AM] Samhita Kims: OP number:20210304915

A 49 year old female came to OPD for regular check up.

K/C/O type 2 DM, on medication- T.Glimi M2 PO/OD

K/C/O HTN, on medication - T.Atenolol PO/OD.

C/O occasional b/l knee pain and lower back ache.

No h/o trauma/ fall.

Not a K/C/O TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:76 bpm

BP:120/70mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

She is a homemaker.She gets up at 6am, finishes house work by 10am, has tea at 10am.

She has lunch at 1pm and sleeps for a while. She has dinner at 8 pm and goes to bed by 9pm.

No recent changes in the daily routine have been reported.

Advise:

Regular exercise.

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 10:30 AM] Samhita Kims: OP number:20210304916

A 52 year old male came to OPD for regular check up.

K/C/O HTN and hypothyroidism, on medication

- T.Thyronorm 100mg

- T.Glimi M1 PO/OD

- T. Met XL 25 PO/OD 

- T. Ecosprin 75.

C/O easy fatiguability and generalised weakness.

No h/o fever, cough, vomiting, burning micturition. 

Not a K/C/O TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:82 bpm

BP:130/70mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

Patient is an Autodriver. He gets up at 6am, has breakfast at 7am and leaves for work by 7:30am.

He comes home for lunch around 1 and stays at home. 

He has dinner at 8 pm and goes to bed by 9pm.

No recent changes in the daily routine have been reported.

Advise:

Regular exercise.

Follow proper medication. 

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 10:52 AM] Samhita Kims: OP number: 20230748046

A 70 year old male came to OPD with complaints of shortness of breath since 1 year, worse on exertion- grade I to II. 

No orthopnea, PND. 

Occasional cough- seasonal variation present, more during winter, productive in nature, white, scanty, non-blood stained. 

No H/O fever, vomiting, chest pain, palpitations, pain abdomen.

Not a K/C/O DM, HTN, TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:86 bpm

BP:130/70mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

Patient stays at home. He gets up at 6am, has breakfast at 7am. 

Has lunch around 12:30pm, takes a nap and sits with neighbours for a while.

He has dinner at 8 pm and goes to bed by 9pm.

No recent changes in the daily routine have been reported.

Advise:

Regular breathing exercises.

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 11:13 AM] Samhita Kims: OP number: 20230743539

A 26 year old male came to OPD with complaints of pain in left side of chest since 1 month. 

The pain started after going to gym and lifting heavy weights. 

No radiation of pain.

No H/o SOB, palpitations, pedal odema. 

No H/o trauma or fall.

Not a K/C/O DM, HTN, TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:76bpm

BP:120/70mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

Patient works at store. He gets up at 6am, has breakfast at 7am. 

And goes to work by 9:30am. Has lunch around 12:30pm. 

Comes home by 6pm and goes to gym for an hour, 

He has dinner at 8 pm and goes to bed by 10pm.

No recent changes in the daily routine have been reported.

Advise:

Adequate rest.

Adequate care firing exercises.

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 11:23 AM] Samhita Kims: OP number: 20230743044

A 55 year old male came to OPD for regular check up. 

He is a K/C/O type 2 DM - not on medication. 

No h/o polyuria, polyphagia, polydipsia.

No h/o tingling, numbness in limbs.

Not a K/C/O HTN, TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR: 80bpm 

BP: 120/70mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

Patient works at store. He gets up at 5am, and opens the store at 6am, has breakfast at 9am. 

Closes the store at 2pm, has lunch and takes some rest. 

Reopens the store at 5pm.

Comes home at 9pm for dinner and sleeps by 10:30pm.

No recent changes in the daily routine have been reported.

Advise:

Adequate rest.

Regular exercises.

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 11:34 AM] Rakesh Biswas Sir: Tell us his routine before he developed diabetes! 

When did he develop it? What symptoms made him visit the doctor that time? 

His abdominal fat and biceps images?

[7/27, 11:43 AM] Samhita Kims: OP number: 20230743592

A 45 year old male came to OPD with complaints of tingling and numbness since 1 week, more during nights. 

No h/o trauma, fall. 

No h/o fever, cough, cold, vomiting, loose stools. 

K/C/O HTN since 3 months, on medication since 1 month (medication not known) 

Not a K/C/O DM, TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:80bpm

BP:120/70mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

Patient works as construction worker. He gets up at 6am, has breakfast at 7am. 

And goes to work by 9:30am. Has lunch around 1pm. 

Comes home by 9pm.

He has dinner at 9:30pm and goes to bed by 10pm.

No recent changes in the daily routine have been reported.

Advise:

Adequate rest.

Follow regular medication.

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 11:45 AM] Samhita Kims: His routine hasn’t changed sir. 

Patient developed diabetes about 1 year ago. It was an accidental discovery when he went for a general checkup.

[7/27, 11:58 AM] Samhita Kims: OP number: 20230743605

A 31 year old male came to OPD with complaints of yellowish discolouration sclera since 2 months. 

H/o fever 2 days ago.

No h/o dark coloured urine/stools

No h/o vomiting, pain abdomen, loose stools. 

Not a alcoholic/smoker.

Not a K/C/O DM, HTN, TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:70bpm

BP:110/70mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

Patient works at a store. He gets up at 6am, has breakfast at 7:30am goes to work by 8am. Has lunch around 1:30pm. 

Comes home by 9pm.

He has dinner at 9:30pm and goes to bed by 10pm.

No recent changes in the daily routine have been reported.

Advise:

Advised admission for further evaluation. Not willing to get admitted.

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 12:06 PM] Samhita Kims: OP number: 20230743598

A 32 year old male came to OPD with complaints of b/l upper and lower limb pain since 1 week. 

C/o itching all over the body since 10days. 

No h/o nausea, vomiting, fever, cold, cough.

Not a K/C/O DM, HTN, TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:76bpm

BP:110/80mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

Patient works as a construction worker. He gets up at 5:30am, has breakfast at 8:30am goes to work by 9pm. Has lunch around 1:30pm. 

Comes home by 6pm.

He has dinner at 8:30pm and goes to bed by 9:30pm.

No recent changes in the daily routine have been reported.

Advise:

Regular exercise.

Adequate hydration.

Change in diet to include more green leafy vegetables.

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 12:12 PM] Samhita Kims: OP number: 20230742997

A 31 year old male came to OPD with complaints of left flank pain, radiating to inguinal region.

Occasionally burning micturition with h/o increased frequency of urine. 

No h/o fever, cough, SOB.

Not a K/C/O DM, HTN, TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:76bpm

BP:110/80mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

Patient works as a construction worker. He gets up at 5am, has tea and leaves for work by 6am.Has lunch around 1:30pm. 

Comes home by 8pm

He has dinner at 8:30pm and goes to bed by 10pm .

No recent changes in the daily routine have been reported.

Advise:

Adequate hydration.

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 12:36 PM] Samhita Kims: OP number: 20230744053

A 18 year old male came to OPD with complaints of cold and headache since 2 weeks.

C/o nasal blockage at night associated with difficulty in breathing.

No h/o chest pain, palpitations, sweating, giddiness.

Not a K/C/O DM, HTN, TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:68bpm

BP:110/80mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

Patient is a student. He gets up at 6am, goes to classes at 7am. Comes back at 9:30 for breakfast and goes to classes at 10am. Has lunch around 1:30pm. 

Comes to the room at 6pm.

He has dinner at 8:30pm and goes to bed by 10pm.

No recent changes in the daily routine have been reported.

Advise:

Regular exercise.

Adequate hydration.

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

[7/27, 12:51 PM] Samhita Kims: OP number: 20230743874

A 32 year old female came to OPD with complaints of tingling and numbness in b/l upper and lower limbs since 20 days.

No h/o trauma/fall. 

No h/o loss of sensation, weakness in b/l limbs.

No h/o polyuria, polyphagia, polydipsia.

Not a K/C/O DM, HTN, TB, asthma , epilepsy, CVA.

On Examination: 

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Temperature: Afebrile 

PR:86bpm

BP:100/60mmhg

CVS: S1 S2+,no murmurs

CNS: NAD

RS: BAE+ NVBS+

P/A: soft,non tender

Daily routine:

Patient works as a labourer. She gets up at 5am,leaves for work by 9am. Has lunch around 1:30pm. Comes home by 7pm.

Finishes household chores by 8pm. He has dinner at 9pm and goes to bed by 10pm .

No recent changes in the daily routine have been reported.

Advise:

Adequate rest. 

Regular exercises.

Dr.Zain ( SR )

Dr.Keerti ( PGY2 )

Dr.Ajay ( PGY1 )

28 july 2023

[7/28, 9:38 AM] +91 98486 60281: OP no:20230738174

A 65 year old female came with complaints of tightness in chest since 6 months and tingling sensation of left foot and leg since 6 months

No history of fever,burning micturition 

No complaints of shortness of breath,palpitations,chest pain

K/C/O HTN since one yr

Not a K/C/O DM,epilepsy,CVA,CAD,asthma

On Examination: 

Patient is conscious,coherent and cooperative

No pallor,icterus,lymphadenopathy, clubbing,cyanosis 

Temp:Afebrile

PR:80bpm

BP:110/60mmhg

RR:18bpm

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

Patient works as agricultural labourer.she wakes up at 6am,does household work,eats at 9am and goes to work and have lunch at 1pm and come back from work at 5pm,prepares dinner and have it at 8pm and sleeps at 9pm.

Advice:

Symptomatic treatment

[7/28, 9:46 AM] +91 6309 842 248: Op :20210320149

A 53 years old patient came to opd with 

C/o

-came for regular check up 

-c/o tingling and numbness of both lower limb

No h/o fever, fatigue and loss of appetite 

Past history-

K/c/o - T2 DM since 8 years and is on T.sitagliptin. 50mg+T.metformin 500mg ,

T.glimi m2 po/bd 

T.dapagliflozin 5mg po/od 

Not a k/c/o HTN, thyroid abnormalities, asthma,TB,and epilepsy

On examination 

Patient is conscious,coherent and cooperative 

Temp- afebrile 

PR-90BPM

Bp- 100/70mmhg

RR-16cpm 

Cvs-S1,S2 heard, no murmurs 

Resp- BAE+ , NVBS heard 

P/A- soft , nontender 

Advice-

Advised for follow up through pajr for diabetes 

Daily routine- 

He wakes up at 5AM then he goes for a 3-5km walk (somedays if he can’t make in the morning he will go for a walk at around 6 PM). He has breakfast(idly/chapathi/ravva upma)and goes to drive auto at around 2 he has lunch(rice with curry) the he takes rest for 2 hrs and will go to drive again. At around 8PM he comes home and has dinner(jonna chapathi-2pcs) and goes to sleep.

[7/28, 10:10 AM] Saranya Mukarjee KIMS: Maybe with a notion to target the goal via different mechanisms of actions sir 

But there can be adverse effects of one drug which may need to be treated with another drug and the cascade continues..

[7/28, 10:12 AM] Rakesh Biswas Sir: That's pathophysiologic rationale bordering on opinion 

How about sharing some efficacy trial data in the pico format to support your opinion?

[7/28, 10:13 AM] +91 98486 60281: OP no:20230744432

A 35 year old male came to opd with complaints of bleeding per rectum since 5 months,now occasionally and complaints of generalized weakness

No complaints of bleeding manifestations(no petechiae/rash),fever,loose stools,vomiting

No history of constipation

Haemorrhoidectomy done 5 months back.

Not a K/C/O HTN,DM,Asthma,thyroid,epilepsy

On Examination: 

Patient is conscious, coherent and cooperative

No pallor,icterus,clubbing,cyanosis, lymphadenopathy 

Temp:Afebrile

PR:86bpm

BP:120/80mmhg

RR:16cpm

CVS:S1 S2+,no murmurs

CND:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

Occupation: Lorry driver 

Patient goes to work (loading and unloading of materials) for alternate months and takes rest at home or does agricultural work on other months.

Patient wakes up at 8am,goes to work at 10am,lunch at 1pm,does work and sleep at 8pm and wakes up at 2am if any work and goes to work.

[7/28, 10:19 AM] Saranya Mukarjee KIMS: Ok sir

[7/28, 10:21 AM] Rakesh Biswas Sir: What work in his non driving daily routine does he do?

How has it changed since last 5 months?

[7/28, 10:51 AM] +91 6309 842 248: Op :20210211413

A 57 years old patient came to opd with 

C/o

-pedal Edema since 10days 

-occasionally palpitations 

No h/o sob,chest pain ,Orthopnea,pnd 

No decreased urine output 

No h/o fever, fatigue and loss of appetite , loose stools , constipation, Vomitings 

Past history-

H/o haemorroidectomy done 3yrs back 

Not a k/c/o DM,htn,thyroid abnormalities, asthma,TB,and epilepsy

On examination 

Patient is conscious,coherent and cooperative 

Temp- afebrile 

PR-88BPM

Bp- 120/90mmhg 

RR-16cpm 

Cvs-S1,S2 heard, no murmurs 

Resp- BAE+ , NVBS heard 

P/A- soft , nontender 

Advice-

Advised to get admitted 

Daily routine -

Occupation- construction work 

He wakes up at 5 o clock and does his daily chores and drinks tea and goes for work and at 9 he has his breakfast fast and at 12 he has lunch and takes rest for 1hr and goes back to work and comes back at 7 o clock and freshen up and has his dinner 8 o clock and sleeps at 9:30pm.

[7/28, 11:24 AM] Manasa Samirishetty Kims: Op :20210211413

A 57 years old patient came to opd with 

C/o

- Right loin pain radiating to the groin since 1 week

No h/o sob,chest pain ,Orthopnea,PND

No h/o fever, fatigue and loss of appetite , loose stools , constipation, Vomitings 

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-88 BPM

Bp- 130/70mmhg 

RR-16cpm 

Cvs-S1,S2 heard, no murmurs 

Resp- BAE+ , NVBS heard 

P/A- soft , nontender 

Advice-

Symptomatic treatment

Daily routine -

Occupation- weaver

He wakes up at 6 o clock and does his daily chores and drinks tea and starts work and at 9 he has his breakfast fast and at 1pm he has lunch and takes rest for 1hr and goes back to work at 3pm and comes back at 6 o clock and freshen up and has his dinner 9o clock and sleeps at 10pm.

[7/28, 12:11 PM] Manasa Samirishetty Kims: Op :20230745444

A 19 years old patient came to opd with 

C/o

- chest pain since 3 days

No h/o sob,chest pain ,Orthopnea,PND

No h/o fever, fatigue and loss of appetite , loose stools , constipation, Vomitings 

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-92 BPM

Bp- 120/70mmhg 

RR-16cpm 

Cvs-S1,S2 heard, no murmurs 

Resp- BAE+ , NVBS heard 

P/A- soft , nontender 

Advice-

Symptomatic treatment

Daily routine -

Occupation- Nursing student

She wakes up at 7am and gets ready and has her breakfast fast by 8 and goes to clg and at 1pm she has lunch and goes back to college 2pm and comes back at 4pm and freshen up eat snacks at 5pm and takes rest till 7pm, eats dinner 8pm and studies till 10pm and sleeps at 10:30pm.

[7/28, 12:49 PM] Manasa Samirishetty Kims: Op :20230744803

A 30 years old patient came to opd with 

C/o

- headache since 8 months associated with neck pain

No h/o sob,chest pain ,Orthopnea,PND

No h/o fever, fatigue and loss of appetite , loose stools , constipation, Vomitings 

Past history-

K/c/o HTN since 1 months (?unknown medication)

Not a k/c/o DM,thyroid abnormalities, asthma,TB,and epilepsy

On examination 

Patient is conscious,coherent and cooperative 

Temp- afebrile 

PR-80 BPM

Bp- 140/80mmhg (did not take medicine)

RR-16cpm 

Cvs-S1,S2 heard, no murmurs 

Resp- BAE+ , NVBS heard 

P/A- soft , nontender 

Advice-

Symptomatic treatment

Daily routine -

Occupation- farmer

He wakes up at 8am and does his daily chores and has breakfast at 9am and goes to field and come back 1pm he has lunch and takes rest and goes back to work at 2pm and comes back at 5pm and has freshen up and has tea, his dinner 8o clock and sleeps at 10pm.

[7/28, 2:39 PM] Sowji: OP :20230739376

A 30 years old male came to opd with 

C/o

Chest pain since 3 days

No radiation to left hand 

No orthopnea, no PND

No h/o SOB or palpitations 

No h/o fever, cough, cold and vomitings 

PAST HISTORY-

K/c/o HTN since 2 months and on medication 

Not a k/c/o DM,thyroid abnormalities, asthma,TB and epilepsy

ON EXAMINATION

Patient is conscious,coherent and cooperative 

Temp- afebrile 

PR-88BPM

Bp- 120/90mmhg 

RR-16cpm 

CNS: NFND

CVS: S1,S2 heard, no murmurs 

RS: BAE+ , NVBS heard 

P/A: soft , nontender 

Advice:

Adequate rest

Avoid lifting heavy weights

Daily routine:

Occupation- Farmer

He wakes up at 4 AM and does his daily chores and has breakfast at 8AM. He goes to the field and comes back at 2PM, he has his lunch and takes rest for an hour . He goes back to work at 3PM. He has tea at 5PM and comes back to his home at 7PM and freshens up. He has his dinner at 8PM and sleeps by 10PM.

[7/28, 3:07 PM] Shubankar: OP number: 20230745956

A 28 year old Male came to opd with complaints of retrosternal pain since 7 months 

Retrosternal pain radiating to left side of chest

H/o regurgitation of food sometimes 

No complaints of fever, vomitings, loose stools, cold, cough, shortness of breath, palpitations, orthopnea PND

N/K/C/O DM  HTN ASTHMA TB EPILEPSY CVD CAD

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile

PR:86bpm

BP:110/70mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+ NVBS+

P/A:soft,non tender

Daily routine:

Occupation:Student 

Patient wakes up at 6am and does household chores and has breakfast at 8am. Then goes to college. He has is lunch by 1pm. He comes back home at around 6 pm and studies for 2-3 hrs. He has his dinner at 9pm and goes to sleep around 11pm. 

Advise:

Avoid lifting heavyweights 

Regular exercise 

Adequate rest

[7/29, 12:49 PM] Neerja KIMS: OP number: 20230746740

A 32 year old female who is homemaker  by occupation came with chief complaints of Shortness of breath MMRC grade 2 since 1 month relieved on rest.

H/o Headache ,Easy fatiguability  since 1 month

Also complains of dizziness and occasional palpitations. 

N/K/C/O Diabetes, Hypertension

  Asthma,TB,Epilepsy,Thyroid disorders 

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile

PR:82bpm

BP:110/70mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+, NVBS+

P/A:soft,non tender

Daily routine:

Patient wakes up at 6am and takes tea at around 7am and  does household activities and  until 12 pm .She takes her lunch   around 1 pm.Takes nap for 1 hour. She drinks tea at around 4pm .she takes her dinner  at around 9 pm and goes to sleep around 11pm. 

Advise:

Symptomatic treatment

Adequate rest

Iron rich diet

[7/29, 12:56 PM] Neerja KIMS: Op no. 20210510749

A 32 year old female came with a complains of Pain in left side of chest and shortness of breath since 1 day.

Palpitations+

No H/o Giddiness, sweating ,orthopnea, PND 

No complaints of Nausea and Vomiting 

N/k/c/o DM,HTN,TB, Epilepsy , thyroid disorders 

O/E:- 

Pt. Is C/C/C

BP:- 110/80 mmHg

PR:-  82 bpm.

RR:18 cpm

CVS:- S1 and S2 heard, no murmurs .  

RS:- BAE ,no additional sounds. 

P/A:-  soft and not tender.

CNS:- NFND

Daily routine- 

Occupation: vegetable seller 

Wakes up at 6am has breakfast at 8am and goes to vegetable store for work and has lunch at 1pm and continues her work she goes back home at 7pm and has dinner at 8pm and goes to bed at 10pm.

Advice:

 symptomatic treatment

Adequate rest

[7/29, 2:22 PM] Neerja KIMS: Op no :20230746808

A 45 year old female labourer came to opd with C/O of neckpain  since 2months

which is dragging type, non radiating no aggrevating factors

C/o lower backache aggrevated on bending down 

H/o lifting heavyweights 

N/K/C/O DM ,HTN,CAD ,epilepsy and TB .

On examination:

Bp:120/70mm hg

Pulse : 85 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :S1S2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She is a labourer by occupation.She wakes up at 5am  completes her household works by 9 am and has her breakfast at 10:00 am.She goes to her work at 10 30  am and in between her work she has her lunch at 1 pm.She comes back to home from her work by 6 pm, has her dinner at 8 pm and sleeps by 10 pm. 

Advice : 

1)symptomatic treatment 

2)Avoid lifting heavyweights 

Dr.Zain(SR)

Dr Narsimha reddy(pg y2)

Dr Nithin( pg y1)

[7/29, 2:25 PM] Neerja KIMS: OP number: 20230747258

A 23 year old Male who is a daily wage worker by occupation came with

C/o epigastric pain since 2days. radiating to left hand 

Associated with bloating and belching aggrevated on having spicy food.

No c/o giddiness ,sweating, dizziness 

No H/o orthopnea, PND

N/K/C/O Dm,HTN,Asthma,TB , epilepsy ,Thyroid disorders 

On Examination: 

Patient is conscious,coherent,cooperative

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

Temperature: Afebrile

PR:78 bpm

BP:110/70mmhg

CVS:S1 S2+,no murmurs

CNS:NAD

RS:BAE+, NVBS+

P/A:soft,non tender,Bowel sounds heard 

Daily routine:

Occupation: Daily wage worker

Patient wakes up at 7am  and has breakfast at 9am. He goes to work by 10 am.He takes rice at around 1pm. He comes back home at around 6pm 

No recent changes in his daily routine.

Treatment

1.Symptomatic treatment 

2.Avoid spicy food.

3.Adequate hydration

Dr.Zain(SR)

Dr.Narsimha Reddy(PGY2)

Dr.Nithin (PGY1)

[7/29, 2:37 PM] Neerja KIMS: Op no :20230746758

A 30 year old female  came to opd with C/O  Shortness of breath MMRC grade1 since 1 month 

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

C/o Back pain no aggrevating factors

K/c/o Hypothyroidism  using Tab Thyronorm 50 mcg

N/K/C/O DM ,HTN,CAD ,epilepsy and TB .

On examination:

Bp:130/80mm hg

Pulse : 76bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :S1S2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She is a computer operator.She wakes up at 5am  completes her household chores by 8 am and has her breakfast at 08:30 am.She goes to her work at 9 00 am and in between her work she has her lunch at 1 pm.She comes back to home from her work by 6 pm, has her dinner at 8 pm and sleeps by 10 pm. 

Advice : 

1)symptomatic treatment 

2)Adequate rest 

Dr.zain(SR)

Dr Narsimha reddy(pg y2)

Dr Nithin( pg y1)

[7/29, 2:40 PM] Neerja KIMS: Op no -20230747308

A 70 year old  Patient came to opd with C/o bloating sensation after taking food since 1 month.

Pain in Epigastric region burning type since 1 month

Non radiating ,aggrevated by  spicy food

No relieving factors 

No h/o palpitations, sweating

No h/o shortness of breath 

No c/o belching ,regurgitation

No Addictions 

Not a k/c/o-DM ,HTN,Tuberculosis,CAD,Asthma ,thyroid disorders 

 Examination: Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 76 bpm

Bp: 110/70mm Hg

Rr - 20cpm

Mild pallor 

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NAD

 Daily routine-

Patient occupation farmer 

Patient wake up 6 am   does all feild work,have some tea at 9 Am and lunch at 1pm and take rest for some time and dinner at 8 pm and go bed at 10 pm

Advice 

Avoid spicy food and non veg

Intake of plenty of water

Symptomatic treatment

Dr.Zain(SR)

Dr.Narsimha PGY2

Dr. Nithin PGY1

[7/29, 2:43 PM] +91 93819 75404: Op  no- 20230746812

A 18 yr old female (nursing student)came to opd with a

C/o-fever since yesterday morning 

High grade,continues associated with chills and rigors 

C/o cold ,cough since 1 day

Throat irritation +

Headache+

No c/o SOB,chest pain, pain abdomen, burning mitcuration 

Not a k/C/o-DM ,CAD,CVA,seizures,HTN,thyroid, TB

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 92 bpm

Bp: 110/70 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-

SHE is a nursing student 

Patient wake up 5 am   and study for 1 hour then get ready for college have some breakfast  . lunch at 1pm and goes for come back to hostel by 5 pm take rest for some time and study for some time and dinner at 8 pm and go bed at 11 pm

Yesterday she woke up at 6:30 am she had squeezing type of abdominal pain and she has head bath with cold water (for last 3 days)she went to college and came back to hostel by 5pm .she 

Had weakness and raise of temperature so she took TAB .DOLO and

 also steam inhalation then she felt little better and in the morning again she had fever.

DR. ZAIN(SR)

DR.NARSIMHA(PG2)

DR.NITHIN(PG1)

[7/29, 3:06 PM] Neerja KIMS: Op  no- 20230746810

A 20yr old female  student came to opd with 

C/o giddiness since 1 month

C/o Easy fatiguability since 1 month

Headache+

No c/o Shortness of breath,chest pain,palpitations, pain abdomen, burning micturition 

Not a k/C/o-DM ,CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

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: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine-

SHE is a nursing student 

Patient wakes up by 5 am  and studies for 1 hour then gets ready for college .She  takes her breakfast at around 8 am and lunch at 1pm and goes back to college  and comes back to hostel by 5 pm  and  takes her dinner at 8 pm and sleeps by 11 pm

Not willing for admission 

Advice

Adequate rest

Symptomatic treatment 

DR. ZAIN(SR)

DR.NARSIMHA(PG2)

DR.NITHIN(PG1)

[7/29, 3:38 PM] Neerja KIMS: Op no: 20230747798

A  23 year old female mentally challenged since birth (History given by pt attender)

complains of Involuntary movements of upper and lower limbs  4 episodes yesterday  each lasting for 2 to 3 minutes .

Associated with tongue bite ,frothing from mouth and uprolling of eyes

No Involuntary micturition ,No Involuntary defecation 

H/o seizures since 5 years 1 episode of seizures since then.

H/o usage of medication only for 1 year

N/K/C/O DM,thyroid ,bronchial asthma

General examination:

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

Vitals-

Temperature: Afebrile

PR: 64bpm

BP: 110/70 mmHg

Systemic examination:

CVS:S1 S2  heard,no murmurs 

P/A: soft ,non tender,Bowel sounds heard

RS:  BAE+ NVBS+,

CNS-

Reflexes  Right.   Left

B                3+     3+

T.               3+         3+

S.               3+       3+

K.               3+    3+

A.                        

Plantar.     Extensor.    Extensor 

  

Power -Not able to elicit

TONE - 

RIGHT UL- N

LEFT U/L -N

RIGHT LL - N

LEFT LL - N

Daily routine 

Patient wakes up around 7 am and gets ready and eats breakfast with her mother's help at around 9 am.She takes her lunch at around 1pm and takes  nap for 2 hours .she gets up in the evening and walks outside for sometime .She has her dinner at 8 pm and goes back to sleep by 9 pm.

Dr.zain (SR)

Dr.Narsimha(PGY2)

Dr.Nithin(PGY1)

Advice

Patient was advised for admission.

[7/31, 10:18 AM] Hemanth 2k18 KIMS: Op  no- 20230748911

A 45yr  old female farmer by occupation came to opd with 

C/o Easy fatiguability since 1 year 

c/o Shortness of breath Grade 2 since 1 week. 

No H/o Heavy flow during menstruation.

No H/o bleeding per rectum 

Not a k/C/o-DM ,CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82 bpm

Bp: 90/60 mm Hg

Rr - 22cpm

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine-

SHE is a Farmer by occupation 

Patient wakes up by 5:30 am  and does house hold work. She  takes her breakfast at around 8 am and she goes to work  and have lunch at 12:30 pm. she comes back to home  by 6 pm  and  takes her dinner at 9 pm and sleeps by 10:30pm. Her daily routine is not affected due to complaints. 

Not willing for admission 

Advice: 

Adequate rest

Symptomatic treatment 

DR. sushmitha (SR)

DR. pavani (PGY2)

DR. Nithin (PGY1)

[7/31, 10:31 AM] Spoorthy Kims: Op no -20230748884

A 45yr old female patient came to opd with 

C/O SOB grade II since 6 months

Palpitations+

No H/O orthopnea, PND, chest pain, fever

C/O pain in the right upperlimb, lowerlimb since 3months

Tingling sensation +

lower backache +

Pt was diagnosed as DM II 10 days back but not using any medication. 

Not a k/c/o -HTN,CAD,CVA, asthma, epilepsy

Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 84bpm

Bp: 140/90 mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

Daily routine-

Pt works as a daily wage worker. 

She wakes up at 4:30am in the morning when there is work otherwise she wakes up at around 5:30am does some household work, prepares breakfast and then goes for work . She eats her lunch at 1:00pm. She gets back home at 6:00pm. After coming back from work she does her daily household chores and then have her dinner at 9:00pm. She sleeps at 10:00pm.

Pt was advised admission but she is not willing to get admitted

Dr. Sushmitha SR

Dr.Pavani PGY2 

Dr.Nithin PGY1

[7/31, 10:35 AM] Rakesh Biswas Sir: Please mention the approximate period of your daily routine. I's it her current daily routine since six months of shortness of breath? 

Has her work as a laborer not been affected at all due to her shortness of breath?

[7/31, 10:36 AM] Rakesh Biswas Sir: Please share the exact details of her work

[7/31, 10:37 AM] Rakesh Biswas Sir: Please share the exact details of her farming work

[7/31, 10:41 AM] Spoorthy Kims: It's her current daily routine sir

She tells that she is facing slight difficulty doing her daily activities so she has come to the hospital

[7/31, 10:49 AM] Hemanth 2k18 KIMS: Her work was mostly ploughing  sir and she is not regularly exposed to pesticides.

[7/31, 10:50 AM] Rakesh Biswas Sir: Give us a better descriptive picture! 

How many days in the year does one need ploughing?

[7/31, 11:08 AM] Spoorthy Kims: Op no -20210521449

A 47yr old male patient came to opd with 

C/O fever since yesterday

Associated with cough and cold

He has low grade fever associated with chills and rigors

Dry cough+

C/O burning micturition since yesterday

No H/O vomitings, loose stools

No H/O rash, bleeding diathesis  

Pt is a K/C/O HTN since 4 years on medication T. Amlokind AT, T. Telma AT (9pm) 

K/C/O DM II since 4 years on medication T. Glimi M1

Not a k/c/o -CAD,CVA, asthma, epilepsy

Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 80bpm

Bp: 110/80 mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

Daily routine-

Pt is a gold smith who makes gold rings, chains , earrings. 

He wakes up at 6:00am in the morning , occasionally does yoga, has green tea, eats his breakfast at 8:00am then does his work. He eats his lunch at 1:00pm. He naps for about an hour in the afternoon. Then he wakes up and gets back to work. 

He does his dinner at 9:00pm and sleeps at 11:00pm

His daily routine has not been affected due to his current complaints. 

Pt was advised admission but he denied

Dr. Sushmitha SR

Dr.Pavani PGY2 

Dr.Nithin PGY1

[7/31, 11:44 AM] Hemanth 2k18 KIMS: Op  no- 20230749504

A 60yr old female  came to opd with 

c/o Headache and neck pain since 3 months. 

H/o nausea 

Associated with photophobia and phono phobia

She is a k/c/o HTN,DM since 30 years. 

Not a k/C/o-CAD,CVA,seizures,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 84 bpm

Bp: 140/70 mm Hg

Rr - 22cpm

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine- she is a house wife.

Patient wakes up around 6:00 am and takes tea at 7:00 am and does house hold activities until 10 am. She takes her breakfast at around 10:30 am. she takes her lunch at 1:30 pm. Takes nap for 1 hr. she drinks tea around 4:00pm. she takes her dinner around 9:00 pm and goes to sleep around 11:00 pm. Her daily routine is not affected due to complaints. 

Not willing for admission 

Advice: 

Adequate rest

Symptomatic treatment 

DR. sushmitha (SR)

DR. pavani (PGY2)

DR. Nithin (PGY1)

[7/31, 12:03 PM] Spoorthy Kims: Op no -20230749510

A 40yr old female patient came to opd with 

C/O burning sensation of both feet (only in the central part of plantar surface of the foot) since 6 months

Aggravates on walking ,relieved on medication (medication unknown) 

C/O giddiness

C/O disturbed sleep due to burning sensation in the feet. 

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

Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 80bpm

Bp: 110/80 mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

Daily routine-

Pt is a farmer who works in her own lemon plantation.

She wakes up at 6:00am in the morning, does some household work , eats her breakfast at 8:00am and goes to work. Then she has her lunch at 1:00pm , takes a nap for an hour. She has her dinner at 9pm and usually sleeps at 10pm.

Because of her current complaints her daily activities are being affected. 

Pt was advised admission but she denied

Dr. Sushmitha SR

Dr.Pavani PGY2 

Dr.Nithin PGY1

[7/31, 12:11 PM] Hemanth 2k18 KIMS: Op  no- 20230749597

A 55yr old male  came to opd with 

c/o pain abdomen in epigastric region and umbilical region since 2 months 

No H/o nausea and sweating 

No H/o Fever.

PAST HISTORY: He is a k/c/o HTN since 6 months and on medication 

Not a k/C/o-Dm, CAD,CVA,seizures,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 86 bpm

Bp: 160/100  mm Hg

Rr - 22cpm

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine- He is a farmer by occupation 

Patient wakes up around 5:30 am and does his daily chores till 8:00 am. He  takes breakfast at around 9:00am. He takes his lunch at 1:00pm. And takes rest for 1 hr. He goes back to work at 3:30 pm . He comes back to home around 6:30 pm and freshens up. He takes his  dinner around 8:30 pm and goes to sleep around 10:00 pm. His  daily routine is not affected due to complaints. 

Not willing for admission 

Advice: 

Adequate rest

Symptomatic treatment 

DR. sushmitha (SR)

DR. pavani (PGY2)

DR. Nithin (PGY1)

[7/31, 12:14 PM] Spoorthy Kims: Op no -20230749624

A 18yr old female patient came to opd with 

C/O fever since 3 days

C/o sore throat 3 days

Associated with cold and dry cough

Low grade fever not associated with chills and rigors. 

No H/O burning micturition

No H/O loose stools

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

Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 82bpm

Bp: 110/70 mm Hg

Rr - 20cpm

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

Cvs: S1 S2 heard, no added sounds

Rs: BAE+, NVBS +

P/a:  soft, non tender

CNS - NFD

Daily routine-

Pt is a 2nd year BSc Nursing student. 

She wakes up at 6:00am in the morning, gets ready, eats her breakfast at 7:30am  and goes to college. Then she has her lunch at 1:00pm , comes back home at 4:00pm . Then she studies for a while and has her dinner at 9pm and usually sleeps at 10pm.

Her daily activities are not affected by her current complaints. 

Pt was advised admission but she denied

Dr. Sushmitha SR

Dr.Pavani PGY2 

Dr.Nithin PGY1

[7/31, 1:01 PM] Spoorthy Kims: Op no -20230749617

A 78yr old male patient came to opd with 

C/O B/L pedal edema (pitting type) since 20 days

Aggravated on walking, relieved on lying in supine position

No H/O decreased urine output

No H/O SOB

Pt is a K/C/O DM II since 15 years

On Tab. Metformin 500mg PO/OD

Not a k/c/o - HTN, CAD,CVA, asthma, epilepsy

Examination: Patient is conscious, coherent, cooperative 

Temp: Afebrile

Pr: 82bpm

Bp: 150/90 mm Hg

Rr - 20cpm

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- (current) 

Pt used to work as a farmer in paddy fields 10yrs back, but at present he stays at home due to his old age. 

Pt usually wakes up at 6:00am in the morning, drinks tea , eats breakfast at 8:00am and then eats his lunch at 1:00pm. He takes an afternoon nap for an hour. He drinks tea in the evening, spends time with family, eats dinner at 9:00pm and sleeps at 10:30pm.

His daily activities have been affected due to his current complaints. 

Pt was advised admission but he denied

Dr. Sushmitha SR

Dr.Pavani PGY2 

Dr.Nithin PGY1

[7/31, 1:11 PM] Hemanth 2k18 KIMS: Op  no- 20230749633

A 70yr old male  came to opd with 

c/o Neck pain and lower back pain since 1 year. Which is of dragging type.

The patient also complaints of decreased appetite and giddiness since 10 days. 

Not a k/C/o-HTN, Dm, CAD,CVA,seizures,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 76bpm

Bp: 120/60  mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine- patient used to work as a daily wage labourer in construction sites 5 years back, But at present he stays at home due to his old age.

Patient wakes up around 7:00 am and does his daily chores till 8:30am. He  takes breakfast at around 9:00am. He takes his lunch at 1:30pm. And take  nap  for 1 hr.He drinks tea at 4:30 pm and spends time with family. He takes his  dinner around 9:00 pm and goes to sleep around 10:3 0 pm. His  daily routine is not affected due to complaints. 

Not willing for admission 

Advice: 

Adequate rest

Symptomatic treatment 

DR. sushmitha (SR)

DR. pavani (PGY2)

DR. Nithin (PGY1)

[7/31, 2:51 PM] Hemanth 2k18 KIMS: Op  no- 20230750066

A 35yr old female came to opd with 

c/o headache since 1 year, on and off, throbbing type, sudden in onset.

Associated with photophobia, vomitings, neck pain.

No h/o chest pain, sob 

No h/o weight loss, Burning micturition. 

Not a k/C/o-HTN, Dm, CAD,CVA,seizures,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 76bpm

Bp: 120/80  mm Hg

Rr - 16cpm

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine- patient is a house wife 

Patient wakes up around 6:00 am and does household activities till 7:30 am. She takes breakfast at around 9:00am. She takes her lunch at 1:30pm. she drinks tea at 4:00 pm. she takes her dinner around 9:00 pm and goes to sleep around 10:30 pm. Her daily routine is not affected due to complaints. 

Not willing for admission 

Advice: 

Adequate rest

Symptomatic treatment 

DR. sushmitha (SR)

DR. pavani (PGY2)

DR. Nithin (PGY1)

[7/31, 3:40 PM] Hemanth 2k18 KIMS: Op  no- 20230750172

A 30yr old female came to opd with 

c/o low grade fever not associated with chills and rigor since 7 days and generalised weakness since 2 days and decreased appetite since 2 days 

No h/o cold, cough

No h/o Burning micturition. 

Not a k/C/o-HTN, Dm, CAD,CVA,seizures,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 60bpm

Bp: 110/70  mm Hg

Rr - 18cpm

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine- patient is a farmer and works in the cotton fields. Patient wakes up around 5:00 am and does household activities till 7:30 am. She takes breakfast at around 9:00am. Then go to work. She takes her lunch at 1:30pm. she comes back home at 6:30 pm and freshens up. she takes her dinner around 8:30pm, and goes to sleep around 10:30 pm. Her daily routine is not affected due to complaints. 

Not willing for admission 

Advice: 

Adequate rest

Symptomatic treatment 

DR. sushmitha (SR)

DR. pavani (PGY2)

DR. Nithin (PGY1)

[8/1, 9:41 AM] +91 70365 71541: Op  no- 20230800011

A 30yr old female  came to opd with 

-C/o shortness of breath (grade Il) since 7 years 

-Lower abdominal pain since 1 year

-cough with expectoration +

-No c/o chest pain

-Palpitations present ,no sweating

-sob increases on exposure to cold temperature 

-Lower abdominal pain associated with white discharge in past one month

-present- she is complaining of white discharge every day with sob and cough with weight loss and generalised weakness present

Not a k/c/o

 ,CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82 bpm

Bp: 110/70 mm Hg

Rr - 20 pm

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-

Patient wakes up by 6 am  and she does household activities  till 9:30 am.She  takes her breakfast at around 9 am and lunch at 1pm and she comes back home at 5 pm and freshens up  she takes dinner at around 8 pm and goes to sleep. At 8 pm .she stopped her work since 10 days due to her complaints

Not willing for admission 

Advice

Symptomatic treatment 

DR. Nikhitha(SR)

DR.Haripriya (PG2)

DR.Govardhini(PG1)

[8/1, 9:51 AM] +91 70365 71541: Op  no- 20230800016

A 60 yr old female  came to opd  with complains of

Burning sensation in chest since 3 days

-vomiting- 3 episodes ,food as content,non bilious in nature

-Bloating and belching are absent

Not a k/c/o/CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82 bpm

Bp: 140/70 mm Hg

Rr - 20 pm

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine-

Patient wakes up by 5 am  and she does household activities  till 8 am.She  takes her breakfast at around 9 am and lunch at 1pm and she comes back home at 6 pm and freshens up  she takes dinner at around 8 pm and goes to sleep. At 9 pm 

She is going to work ,her daily activities are not disturbed 

Advice :

Adequate rest

Symptomatic treatment 

DR. Nikhitha(SR)

DR.Haripriya (PG2)

DR.Govardhini(PG1)

[8/1, 10:01 AM] Shivani Reddy. S kims: Op no :20230800026

A 60 year old male came to opd with C/O of  SOB grade 3 and dry cough since 1 day 

H/o abdominal bloating and tightness ,regurgitation is present since 1 day

No H/O of fever,chestpain,palpitations.

No H/O of vomitings and constipation.

Pedal edema and decreased urine output are absent.

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

H/O polypectomy (B/L nasal cavity) 3 months ago.

Had similar complaints of SOB in the past which are decreased after polypectomy.

On examination:

Bp:120/80mm hg

Pulse : 78 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

He is a farmer by his occupation. He lifts heavy weights and sprays pesticides on crops.He wakes up at 6:00 am and has his breakfast at 9:00 am ,goes to his work at 10.00am .He skips his lunch. He comes back to home by 5 pm  and takes rest .He has his dinner at 7 pm ,watches TV and sleeps by 10 pm.

1 year back he stopped going to his work due to his SOB as he have to lift heavy weights.3 months back his SOB is releived after polypectomy.Now He prefers staying at home and takes rest.

Advice : symptomatic Treatment 

Dr.Nikitha(SR)

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)

[8/1, 10:05 AM] Rakesh Biswas Sir: What's your diagnosis?

[8/1, 10:06 AM] Rakesh Biswas Sir: Comes back home at 5PM from where? What does she do till then?

[8/1, 10:08 AM] +91 70365 71541: She is a farmer sir ,she come from her work at 5 pm

[8/1, 10:08 AM] Rakesh Biswas Sir: What work does she do in her farm? Is it the same work 365 days?

[8/1, 10:09 AM] Rakesh Biswas Sir: Same missing data

[8/1, 10:10 AM] Rakesh Biswas Sir: Diagnosis?

[8/1, 10:10 AM] +91 70365 71541: Op  no- 20230800016

A 60 yr old female  came to opd  with complains of

Burning sensation in chest since 3 days

-vomiting- 3 episodes ,food as content,non bilious in nature

-Bloating and belching are absent

Not a k/c/o/CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82 bpm

Bp: 140/70 mm Hg

Rr - 20 pm

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine-

Patient wakes up by 5 am,she is a farmer by occupation  and she does household activities  till 8 am.She  takes her breakfast at around 9 am and lunch at 1pm and she comes back home at 6 pm  from her work and freshens up  she takes dinner at around 8 pm and goes to sleep. At 9 pm 

She is going to work ,her daily activities are not disturbed 

Advice :

Adequate rest

Symptomatic treatment 

DR. Nikhitha(SR)

DR.Haripriya (PG2)

DR.Govardhini(PG1)

[8/1, 10:11 AM] Rakesh Biswas Sir: Share abdominal and biceps lateral view clinical images of every patient and prepare their case reports and PaJR groups after signed informed consent

[8/1, 10:18 AM] +91 70365 71541: Op  no- 20210325801

A 68 yr old female  came to opd  with complains of pain and tingling sensation of left shoulder since 15 years

No hlo trauma

No hlo restriction of movements-but she is unable to abduct the left shoulder ,intermittent pain is present while abducting the left shoulder 

Neck pain present 

No clo fever

-she also complains of pain with swelling of 2 x 2cm2 of left breast since 1 day 

-No H/o trauma

K/c/o DM type 2 since  8 years and she is on unknown medication

Not a k/c/o/ CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82 bpm

Bp: 140/90 mm Hg

Rr - 20 pm

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 a home maker by occupation,Patient wakes up by 6 am  and she does household activities  till 11 am.She  takes her breakfast at around 8 am and lunch at 1pm and she takes nap in the afternoon for 2 hrs And she takes her dinner at around 8 pm and goes to sleep at 9 pm 

Her daily activities are not disturbed 

Advice :

Symptomatic treatment 

DR. Nikhitha(SR)

DR.Haripriya (PG2)

DR.Govardhini(PG1)

[8/1, 10:38 AM] +91 70365 71541: Op  no- 20230800495

A 19 yr old female  student came to opd with 

Fever since 2 days

Throat pain since 2 days

Giddiness since 1 day -followed by fall

Fever which is of low grade , intermittent type,relieved on taking medication.

Vomiting -one episode ,food particles as content ,no bilious ,non projectile

Not a k/c/o DM ,CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82 bpm

Bp: 110/70 mm Hg

Rr - 20cpm

Mild pallor 

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine-

She is a nursing student 

Patient wakes up by 6 am  and studies for 1 hour then gets ready for college .She  takes her breakfast at around 8 am and lunch at 1pm and goes back to college  and comes back to hostel by 4 pm  and  takes her dinner at 8 pm and sleeps by 11 pm

Not willing for admission 

Advice

Adequate rest

Symptomatic treatment 

DR .NIKHITHA (SR)

DR HARIPRIYA (PG2)

DR GOVARDHINI(PG1)

[8/1, 10:40 AM] Shivani Reddy. S kims: Op no :20230800031

A 73 year old male came to opd with C/O of  tingling and burning sensation of b/l feet since 6 days not associated with pain.

H/O abdominal tightness,belching , regurgitation and constipation is present.

No H/O of fever,chestpain,palpitations.

No H/O of vomitings and constipation.

Pedal edema and decreased urine output are absent.

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

K/C/O DM since 9 years and  on regular medication.

On examination:

Bp:120/80mm hg

Pulse : 78 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

He was a toddy worker by his occupation. He used to climb tall trees for toddy.

9 years back he stopped going to his work due to DM

He wakes up at 4:00 am and has his breakfast at 6:00am(roti) ,8am (millets jaava), 10 am(rice) .He takes rest for sometime.At 5pm he watches TV,goes for a walk ,has some tea and snacks.He has his dinner  at 9.00pm ,sleeps by 10 pm.

9 years back he stopped going to his work due to his DM.Now he prefers staying at home and takes rest.

Since 6 days there is no change in daily routine due to his symptoms.

Advice : symptomatic Treatment 

Dr.Nikitha(SR)

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)

[8/1, 11:01 AM] Shivani Reddy. S kims: Op no :20210511980

A 32 year old female came to opd with C/O of  yellow coloured ,drycough with intermittent expectoration since 20 days.

High grade fever with diurnal variations since 1 day.A/O chills and rigor

 grade 3 and dry cough since 1 day .

C/O sore throat since 1 day.

No H/O nausea ,vomiting,abdominal pain and burning micturition.

N/K/C/O TB,epilepsy, CVA,CAD,HTn and DM

On examination:

Bp:120/80mm hg

Pulse : 78 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She is a cook by her occupation.She wakes up at 6:00 am ,goes to her work at 6:30 and has her breakfast at 9:00 am.She has her lunch in between her work at 1pm .She comes back to home by 5 pm and again goes to work at 7 pm to cook food.At 9 pm she has her dinner and sleeps at 10 pm.

Due to her fever she stopped going to her work since 1 day.

 

Advice : symptomatic Treatment 

Dr.Nikitha(SR)

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)

[8/1, 11:12 AM] +91 70365 71541: Op  no- 20230800455

A 39 yr old female  came to opd  with complains of

-Dragging type of pain in lower limbs since 4 days, continuous in nature,aggravated on sleeping /sitting, relieved on taking rest

-He also complains of bilateral loin pain which is on and off in nature since4 days

-No h/o low back pain 

-obtained menopause 1 year ago

Not a k/c/o/M ,CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82 bpm

Bp: 120/80 mm Hg

Rr - 18 pm

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine-

Patient is homemaker by occupation .Patient wakes up by 5 am  and she does household activities  till 8 am.She  takes her breakfast at around 9 am and lunch at 1pm and she takes nap for about 2 hrs and freshens up  she takes dinner at around 8 pm and goes to sleep at 9 pm 

 Her daily activities are not disturbed

Advice :

Symptomatic treatment 

DR. Nikhitha(SR)

DR.Haripriya (PG2)

DR.Govardhini(PG1)

[8/1, 11:24 AM] Shivani Reddy. S kims: Op no :20230801020

A 27 year old female came to opd with C/O neckpain since 10 days.

 C/O headache with retroorbital pain  with giddiness since 10 days

A/O with nausea,vomiting ,photophobia ,phonophobia since 10 days.

No H/O tinnitus,watering of eyes and blurring of vision

N/K/C/O TB,epilepsy, CVA,CAD,HTn and DM

On examination:

Bp:120/80mm hg

Pulse : 78 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

She is a farmer by her occupation.She wakes up at 6:00 am ,does her  household chores  by 9 am  and has her breakfast at 9:30 am.She goes to her work at 10 am.She has her lunch in between her work at 1pm .She comes back to home by 5 pm .She relaxes for sometime.  At 9 pm she has her dinner and sleeps at 10 pm.

Due to her headache she stopped going to her work since 10 days

 

Advice : symptomatic Treatment 

Dr.Nikitha(SR)

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)

[8/1, 11:56 AM] +91 70365 71541: Op  no- 20230800455

A 19 yr old male  came to opd  with complains of

Right sided chest pain radiating to infrascapular area since 1 month,which is progressive in nature

-He also complains of sob during pain which is relived after taking water

-No h/o trauma

-No h/o bleeding

Not a k/c/o/DM ,CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82 bpm

Bp: 120/80 mm Hg

Rr - 18 pm

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

 Tenderness in 5th rib , inferior border 

Cvs: S1 S2 heard,No murmurs

Rs: bae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine-

Patient is  student  by occupation .Patient wakes up by 7 am  and   he gets freshen and takes his breakfast till 8 am and goes to college  and he takes lunch at 1pm and he takes nap for about 2 hrs  in afternoon and play games in the evening ,he takes dinner at around 9 pm and goes to sleep at 9:30 pm 

 His daily activities are not disturbed

Advice :

Symptomatic treatment 

DR. Nikhitha(SR)

DR.Haripriya (PG2)

DR.Govardhini(PG1)

[8/1, 11:57 AM] +91 70365 71541: Op  no- 20230800455

A 24 yr old male came to opd  with complains of

Fever since 3 days which is high grade associated with chills and rigors

Loss of appetite present

C/o dry cough 

C/o body pains

No H/o vomitings,sore throat,sob,head ache

No H/o abdominal pain,diarrhea, burning micturition 

Not a k/c/o/M ,CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82 bpm

Bp: 120/80 mm Hg

Rr - 18 pm

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-

Patient is farmer  by occupation .Patient wakes up by 5 am  and he gets freshen up   till 8 am.and goes to work he  takes his breakfast at around 11 am and lunch at 2pm and he goes to work  comes back by 7 pm  freshens up  he takes dinner at around 9 pm and goes to sleep at 9:30 pm 

 He stopped going to work for 2 days due to symptoms 

Advice :

Symptomatic treatment 

DR. Nikhitha(SR)

DR.Haripriya (PG2)

DR.Govardhini(PG1)

[8/1, 2:42 PM] +91 70365 71541: Op  no- 20230800455

A 20 yr old female  came to opd  with complains of

Head ache which is right sided frontal and neck region since 2 months,3-4 episodes /week

-Triggered by prolonged reading and noises 

-Episode lasting for 1 hr

-Relieved spontaneously or after taking naproxen medication

-No diurnal variation

-No photophobia

Not a k/c/o/DM ,CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 82 bpm

Bp: 120/80 mm Hg

Rr - 18 pm

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

Cvs: S1 S2 heard,No murmurs

Rs: blae+, NVBS heard

P/a:  soft, non tender, bowels sounds+

CNS - NFAD

 Daily routine-

She is an Mbbs student.

Patient wakes up by 6:30 am  and she gets freshen up and she  takes her breakfast at around 7:30 am and goes to college and lunch at 1pm and goes to clg ,she comes back by 4 pm and take snacks and goes to library  and  she takes dinner at around 9 pm and goes to sleep at 11 pm 

 Her daily activities are not disturbed

Advice :

Symptomatic treatment 

DR. Nikhitha(SR)

DR.Haripriya (PG2)

DR.Govardhini(PG1)

[8/1, 2:55 PM] +91 70365 71541: Op  no- 20230801235

A 52 yr old male came to opd  with complains of

Pain in both lower limbs radiating from low back to both lower limbs,which is pricking type, aggravated on bending towards and able to squat,non relieving on taking medication.

-No H/o chest pain ,sob, palpitations.

Not a k/c/o/M ,CAD,CVA,seizures,HTN,thyroid disorders, TB,Asthma 

 On Examination-

 Patient is conscious, coherent, cooperative 

Temp: afebrile

Pr: 83 bpm

Bp: 130/70 mm Hg

Rr - 18 pm

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-

Patient is farmer  by occupation .Patient wakes up by 3 am  and goes to work in the morning and comes back home   he  takes his breakfast at aroundl 9 am and lunch at 2pm and he goes to work  comes back by 5 pm  freshens up  he takes dinner at around 9 pm and goes to sleep at 10 pm 

 His daily activities are not disturbed 

Advice :

Symptomatic treatment 

DR. Nikhitha(SR)

DR.Haripriya (PG2)

DR.Govardhini(PG1)

[8/1, 3:11 PM] Shivani Reddy. S kims: Op no :20210325800

A 73 year old male came to opd with C/O  bilateral knee joint pain increased since 1 month.

Increased on walking and relieved on rest.

No H/O swelling,redness and restriction on movements.

K/C/O gout since 10 years and is on medication.

 

N/K/C/O TB,epilepsy, CVA,CAD,HTn and DM

On examination:

Bp:130/80mm hg

Pulse : 78 bpm

RS:BLAE + ,NVBS + , no added sounds 

CVS :s1s2 + no murmurs 

P/A :soft,nontender.

Daily routine: 

He was a driver by his occupation.He stopped driving since 10 years due to his gout

He  wakesup at 7.00am ,does his household chores  by 9 am  and has his breakfast at 9:30 am.He walks and relaxes for sometime.He has his lunch at 12pm.He has some tea at 4 pm and watches TV from 5 to 8pm.He has his dinner by 9pm and sleeps by 10pm.

He stopped driving since 10 years due to his gout.

There is no change in his daily routine due to his current symptoms

 

 

Advice : symptomatic Treatment 

Dr.Nikitha(SR)

Dr Haripriya(pg y2)

Dr Govardhini ( pg y1)