Evidence of workflow done during internship rotation!
Hello everyone This is Navyatha! This is a compailation of work blogs and PAJR created during my medicine rotation!
Life in medicine department is a delicate balance—between patient care and paperwork, professional responsibilities and personal well-being. The lesson lies in mastering this equilibrium, knowing when to push forward and when to pause, ensuring sustained excellence in both professional and personal realms.
Case 1:
https://navyathapothularollno110.blogspot.com/2023/10/this-is-online-e-log-book-to-discuss.html
Chief complaints :
Patient came with chief complaints of fever since 10 days
HOPI
Patient was apparently asymptomatic 10 days back and developed fever which is intermittent high grade relieved on medication
Associated with chills and rigor
Loss of appetite
Not a/s w cold cough
Not a/s chest pain ,palpitations,shortness of breath
Past history:
H/o surgery: umbilical hernia : hernioplasty 30 yrs ago
Not a k/c/o Dm Htn tb asthma
Personal history:
Appetite:decreased
Bowel and bladder habits normal
Diet: breakfast daily at 9:00 am
Skips lunch
Next meal at 7:00pm
Non vegetarian diet on weekends
Addictions: alcoholic consumption
(Whiskey:100 ml) regular basis
Sleep: inadequate
General examination:
Pt is ccc
No signs of clubbing, cyanosis, pallor ,icterus,lymphendenopathy
Vitals :3/10 /23
Bp :130/70
PR:76bpm
Temp:99.7
RR:18cpm
4/10/23:
Bp:110/70
PR:80bpm
Temp: 97.7
RR: 18 cpm
Temp 12pm :
101.1
Provisional diagnosis:
Viral pyrexia under evaluation with thrombocytopenia
Investigation:
RBS - 141 mg/dl
TB - 0.60mg/dl
DB - 0.18 mg/dl
AST -133# IU/l
ALT - 154#IU/l
ALP - #383IU/L
TP - 6.8 gm/dl
Alb - #3.16
A/G ratio -0.87
Blood urea -43#/dl
Ser creat -1.2 mg/dl
Uric Acud - 4.4 mg%
Na -#130
K - 4.0
Cl - 99
Ca - 1.20
Hb - # 11.8
Tlc - #7600
Pcv:34.1#
Mchc:34.6#
Cue - alb and sugars nil
Treatment given:
IV fluilds 0.9% NS @75 ml /hr
TAB DOLO 650mg PO/BD
INJ NEOMOL1gm Iv
INJ THIAMINE 200 mg in 100 ml NS
https://chat.whatsapp.com/KEFCWrHWaW62wkLND07uXI
Case 2:
https://chat.whatsapp.com/JegTWZ98NUoBmjvX7kOJtx
Chief complaints :
Patient came with chief complaints of SOB since 5 days and right lower limb swelling since 15days
HOPI
Patient was apparently asymptomatic 15 days back then had prick foreign body development of Rt LL cellulitis and was treated conservatively outside and incidentally found to have renal failure and was initiated on hemodialysis 5 sessions of HD was done outside and is being referred to our hospital due to financial issues.
Past history:
H/o surgery: CAD S/P CABG done 2 yrs back and is under conservative management for the same.
K/c/o Hypothyroid
Not a k/c/o Dm Htn tb asthma
Personal history:
Appetite: normal
Diet: mixed
Addictions:
Sleep: adequate
General examination:
Pt is ccc
No signs of clubbing, cyanosis, pallor ,icterus,lymphendenopathy
Vitals :4/10 /23
Bp :100/70
PR:89bpm
Temp:afebrile
RR:22cpm
5/10/23:
Bp:100/70
PR:88bpm
Temp: afebrile
RR: 22 cpm
6/10/23:
Bp:100/60
PR:88bpm
RR:20 cpm
Provisional diagnosis:Prerenal AKI on? CKD with Rt LL cellulitis
Investigation:
4-10-23
Hb 6.5
Tlc 10,900
Plt 2.93lakhs
TB 0.71
DB 0.20
AST 56
ALT 29
ALP 188
TP 6.2
ALB 2.08
A/G 0.50
RFT
Urea 233mg/dl
Creat 9.9mg/dl
UA 10.3mg/dl
Na 128
K 4.6
Cl 9.8
Ph 9.4
Case 3:
https://chat.whatsapp.com/FkyBxpaDe8GBcXL5M806Rg
C/o fever : today morning
C/o vomitings: today morning
C/o cough since 1 day
Hopi : pt was apparently asymptomatic then he developed fever which is of high grade ,intermittent a/w chills and rigor , vomitings
( non projectile non bilious watery filled with food particles
No c/o pain abdomen cold loose stools burning Micturition
Previous h/o ?pneumonia 3 months ago
Past History: N/k/c/o HTN , DM , CAD , CVA , epilepsy , thyroid disorders .
Vitals
BP : 130/80
PR : 86/min
RR: 18/min
Temp: 99F
Spo2 : 99%
GRBS : 98mg%
Rx :
IV fluids NS or RL @ 100ml /hr
Inj NEOMOL 1gm IV/SOS (if temp > 101F )
Inj ZOFER 4 mg IV/SOS
Tab PCM 650 mg PO/QID
( 8am ,2Pm , 8pm , 2 Am )
Monitor vitals 4 hrly
Case4:
https://chat.whatsapp.com/KHDbnCURvH2AGZ7EVGnhGN
A 40 year old male came to OPD with complaint of pain in feet and upperlimbs since 1 month
HOPI: pain got aggravated on walking working associated with burning sensation.
Type of pain:Dragging type
Past history:
N/K/C/O :DM, HTN,, Asthma
history of cough, cold
Not associated with burning micturition.
H/o ptb since 6 months
On att medication
The patient was advised to admit for further examination.
The patient was examined in the OP- CNS and Musculoskeletal examination.
Carpopedal spasm on inflating the cuff
Chvostek sign positive
CNS -
LEVEL OF CONSCIOUSNESS - conscious
SPEECH - normal
NO NECK STIFFNESS
KERNIGS SIGN- ABSENT
CRANIAL NERVES- ELICITED
MOTOR SYSTEM- RT LT
TONE UL N N
LL N N
SENSORY SYTEM - ELICITED
POWER RT LT
UL 55 5/5
LL 5/5 4/5
REFLEXES
BICEPS ;
TRICEPS ;
KNEE REFLEX OF RL
- PRESENT
- aching pain near calcaneum and talus junction
GAIT - NORMAL
Provisional diagnosis:H/o ptb since 6 months
Carpopedal spasm?
Treatment:tab PCM 650 for two days
Tab Shelcal po od 7 days
Tab pyridoxine po od 7 days
Pyrinzinamide 15-30 mg
Case5:
https://chat.whatsapp.com/HFHmV5NIhIGKXjrDp4i0GG
A 40 yr old male pt came with chief complaints of pain abdomen since 5 days associated with fever since 2 days.
Pt was apparently asymptomatic 5 days ago then he developed pain abdomen which is diffuse squeezing type radiating to back insidious in onset gradually progressive .
No complaints of vomitings, burning micturition ,cough,cold .
Not k/c/o Htn,Dm,Cad,cva,Asthama,TB
ACUTE PANCREATITIS (NON NECROTIZING TYPE ) Peri pancreatitc fluid collection.
Usg:
Pancreatic body visualised appears bulky
Mild hepatomegaly
Investigations:
Reticulocyte 1.1
Hb: 9.1
Tlc:8600
Plt: 2.96
Pcv 27.7
Cue:
Albumin +++
Sugars nil
Serum iron
Esr:120
Iron :49
Rx:
Nbm
INJ zofer
Iv fluilds ns dns rl @125
INJ tramadol 1amp in 100 ml ns
INJ pan 40 mg iv/bd
INJ piptaz 4.5 Iv tid
INJ neomol 1gm iv bd
I thank all my faculty,senior residents,residents and fellow co interns for giving this tremendous opportunity to dive into this world of medicine!
Thank you
Navyatha pothula
Roll no 75
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