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30 Adult OPD Cases: Clinical Practice & Education Guide

Disclaimer: These are educational case templates for medical students, interns, and residents. All drug doses are for average adults with normal renal/hepatic function unless stated. Always individualize therapy. Sources: Goldman-Cecil Medicine, Textbook of Family Medicine 9e, Katzung Pharmacology 16e, Sleisenger & Fordtran GI 11e.

CARDIOVASCULAR CASES

CASE 1 - Essential Hypertension (Stage 1)

Patient: Mr. Ramesh K., 45 M, office worker Chief Complaint: Headache, occasional dizziness for 3 months History: Non-smoker. Father had hypertension. No chest pain, no shortness of breath. No prior medications. Examination:

BP: 148/94 mmHg (both arms, 2 readings, 5 min apart)
HR: 82 bpm, regular
BMI: 27.4 kg/m²
Fundoscopy: Grade I arteriolar narrowing
No pedal edema, normal heart sounds

Investigations:

FBS: 95 mg/dL
Lipid profile: LDL 138, HDL 42, TG 160
Serum creatinine: 0.9 mg/dL, eGFR >60
ECG: Normal sinus rhythm
Urine R/E: No proteinuria

Diagnosis: Stage 1 Essential Hypertension (BP 140-159/90-99 mmHg)

Management Plan:

Lifestyle: DASH diet, Na <1500 mg/day, aerobic exercise 90-150 min/week, alcohol restriction
Start pharmacotherapy (ACC/AHA 2017: initiate if 10-yr ASCVD risk ≥10% or BP ≥140/90 with risk factors)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Ramesh K.       Age: 45 M       Date: __/__/____
Dx: Stage 1 Essential Hypertension

Rx:
1. Tab. AMLODIPINE 5 mg            1-0-0       × 30 days
   (calcium channel blocker, first-line)

2. Tab. ASPIRIN 75 mg (Ecosprin)   0-0-1       × 30 days
   (if 10-yr CVD risk ≥10%)

Advice:
• Monitor BP at home daily (morning + evening)
• DASH diet, reduce salt intake
• Walk 30 min daily
• Avoid NSAIDs/OCP without consultation

Review: 4 weeks with BP diary
══════════════════════════════════════════════════

Note: If BP not at goal (<130/80) in 4 weeks, add Tab. Losartan 50 mg OD or Telmisartan 40 mg OD.

CASE 2 - Essential Hypertension (Stage 2, diabetic patient)

Patient: Mrs. Sunita D., 54 F, housewife Chief Complaint: Routine check-up, BP 160/100 found at pharmacy History: Known T2DM on Metformin. No chest pain. Mild exertional dyspnea. Examination:

BP: 162/102 mmHg
HR: 78, BMI: 29
Mild ankle edema +
S1 S2 normal, no murmurs

Investigations:

HbA1c: 7.6%
FBS: 148 mg/dL, PPBS: 210 mg/dL
Urine microalbumin/creatinine ratio: 62 mg/g (elevated - early nephropathy)
Creatinine: 1.1, eGFR 62 mL/min
ECG: LVH by voltage criteria

Diagnosis: Stage 2 Hypertension + T2DM + Early Diabetic Nephropathy

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mrs. Sunita D.      Age: 54 F       Date: __/__/____
Dx: Stage 2 HTN + T2DM + Early Nephropathy

Rx:
1. Tab. TELMISARTAN 40 mg          1-0-0       × 30 days
   (ARB - preferred in DM + proteinuria, renoprotective)

2. Tab. AMLODIPINE 5 mg            1-0-0       × 30 days
   (synergistic with ARB for BP control)

3. Tab. METFORMIN 500 mg           1-0-1 with food × 30 days
   (continue existing DM therapy)

4. Tab. ATORVASTATIN 20 mg         0-0-1       × 30 days
   (high CV risk: statin indicated)

Advice:
• BP target: <130/80 mmHg (diabetic patient)
• Monitor serum creatinine and K+ in 2 weeks
• Protein restriction: 0.8 g/kg/day
• Foot care, eye examination due

Review: 2 weeks
══════════════════════════════════════════════════

CASE 3 - Stable Angina

Patient: Mr. Suresh P., 58 M, driver, smoker Chief Complaint: Chest pain on exertion for 2 months, relieved by rest History: Pain is retrosternal, radiates to left arm, lasts 3-5 min with exertion, relieved in 5 min by rest. No pain at rest. Smokes 15 cigarettes/day. Examination:

BP: 138/86, HR 80 bpm
BMI: 26
Normal heart sounds, no murmurs

Investigations:

ECG: Normal at rest
Stress ECG (TMT): ST depression 1.5 mm in leads V4-V6 at 7 METS - positive
Lipids: LDL 168, HDL 38
FBS: 102 mg/dL
Troponin I: Negative

Diagnosis: Stable Angina Pectoris (CCS Grade II)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Suresh P.       Age: 58 M       Date: __/__/____
Dx: Stable Angina (CCS II)

Rx:
1. Tab. ASPIRIN 75 mg (Ecosprin)   1-0-0       × 30 days

2. Tab. ATENOLOL 50 mg             1-0-0       × 30 days
   (beta-blocker: reduces HR, myocardial O₂ demand)

3. Tab. ISOSORBIDE MONONITRATE 
   SR 30 mg                        1-0-0       × 30 days
   (long-acting nitrate; give 8 AM to avoid nighttime hypotension)

4. Tab. ATORVASTATIN 40 mg         0-0-1       × 30 days
   (target LDL <70 mg/dL in high CV risk)

5. GLYCERYL TRINITRATE (GTN) 
   spray 0.4 mg/puff               PRN (1-2 puffs under tongue
                                    during anginal episode)

Advice:
• Stop smoking IMMEDIATELY - most important
• Carry GTN spray at all times
• Avoid sudden heavy exertion
• Referred for Cardiology + Coronary angiography

Review: 2 weeks
══════════════════════════════════════════════════

ENDOCRINE / METABOLIC CASES

CASE 4 - Type 2 Diabetes Mellitus (Newly Diagnosed)

Patient: Mr. Vijay R., 48 M, software engineer Chief Complaint: Increased thirst, frequent urination, fatigue × 3 months History: Weight gain of 8 kg over 2 years. Father had diabetes. Sedentary lifestyle. Examination:

BMI: 31.2 (obese)
BP: 132/84
Acanthosis nigricans on neck
No retinopathy, no peripheral neuropathy

Investigations:

FBS: 176 mg/dL
PPBS (2h post 75g): 265 mg/dL
HbA1c: 8.2%
Lipids: TG 218, HDL 38 (metabolic syndrome)
Creatinine: 0.9, urine albumin: normal
SGPT: 42 U/L (mild fatty liver)

Diagnosis: T2DM, newly diagnosed + Metabolic Syndrome

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Vijay R.        Age: 48 M       Date: __/__/____
Dx: Type 2 DM (newly diagnosed), HbA1c 8.2%

Rx:
1. Tab. METFORMIN 500 mg           1-0-1 (with meals)  × 30 days
   Titrate to 500 mg TDS after 2 weeks if tolerated
   (first-line, weight-neutral, cardioprotective)

2. Tab. EMPAGLIFLOZIN 10 mg        1-0-0 (with breakfast) × 30 days
   (SGLT2i: weight loss, BP reduction, renal/CV benefit)

3. Cap. OMEGA-3 FATTY ACIDS 1g     0-0-1               × 30 days
   (for hypertriglyceridemia)

Advice:
• Target HbA1c: <7.0% (ADA 2024)
• SMBG: fasting + 2h post-prandial daily
• Calorie-restricted diet (1800 kcal/day)
• Walk 150 min/week
• Review in 3 months with HbA1c

Review: 3 months
══════════════════════════════════════════════════

CASE 5 - Hypothyroidism

Patient: Mrs. Priya M., 34 F, teacher Chief Complaint: Weight gain, fatigue, cold intolerance, constipation, hair loss × 6 months History: Heavy menstrual periods. Dry skin. Slow speech noted by family. Examination:

HR: 58 bpm (bradycardia)
BP: 110/70
Dry coarse skin, periorbital puffiness
Goitre: Grade I (mild enlargement)
Delayed ankle reflex relaxation (pathognomonic)
BMI: 29

Investigations:

TSH: 18.4 mIU/L (high) [Normal: 0.4-4.0]
Free T4: 0.6 ng/dL (low) [Normal: 0.9-1.8]
Anti-TPO antibodies: 640 IU/mL (positive - Hashimoto's)
CBC: Hb 10.2 g/dL (normocytic anemia)
Lipids: LDL 152, TG 188

Diagnosis: Primary Hypothyroidism (Hashimoto's Thyroiditis)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mrs. Priya M.       Age: 34 F       Date: __/__/____
Dx: Primary Hypothyroidism (Hashimoto's), TSH 18.4

Rx:
1. Tab. LEVOTHYROXINE (T4) 50 mcg  1-0-0
   Take on EMPTY STOMACH, 30 min before breakfast
   (Start low, titrate every 6 weeks based on TSH)

Advice:
• Do NOT take with calcium, iron, antacids (reduces absorption)
• Expected TSH goal: 0.5-2.5 mIU/L
• Symptoms improve in 4-8 weeks
• Lifelong therapy required
• Pregnancy: increase dose by 30%, notify doctor immediately

Review: 6 weeks with TSH, fT4
══════════════════════════════════════════════════

Dose guide: Starting dose = 1.6 mcg/kg/day (full replacement); start 25-50 mcg in elderly/cardiac patients.

CASE 6 - Hyperthyroidism (Graves' Disease)

Patient: Ms. Kavya S., 28 F, student Chief Complaint: Weight loss despite good appetite, palpitations, heat intolerance, anxiety × 4 months Examination:

HR: 112 bpm, fine tremor of outstretched hands
Exophthalmos (bilateral proptosis)
Diffuse smooth goitre with bruit
Warm, moist skin
BP: 128/60 (wide pulse pressure)

Investigations:

TSH: <0.01 mIU/L (suppressed)
Free T4: 4.2 ng/dL (very high)
Free T3: 12.1 pg/mL (high)
TSH receptor antibodies (TRAb): Positive
Thyroid uptake scan: Diffuse increased uptake

Diagnosis: Graves' Disease (Diffuse Toxic Goitre)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Ms. Kavya S.        Age: 28 F       Date: __/__/____
Dx: Graves' Disease (Hyperthyroidism)

Rx:
1. Tab. CARBIMAZOLE 20 mg          1-0-1           × 30 days
   (antithyroid; titrate dose based on TFT)

2. Tab. PROPRANOLOL 40 mg          1-1-1           × 30 days
   (beta-blocker: controls palpitations, tremor, heat intolerance)
   (NOT definitive treatment, only symptomatic)

Advice:
• Report IMMEDIATELY if sore throat, fever, mouth ulcers
  (agranulocytosis - rare but serious side effect of carbimazole)
• CBC + TFT in 4 weeks
• Discuss definitive options: Radioiodine (¹³¹I) or surgery
• Ophthalmology referral for exophthalmos

Review: 4 weeks
══════════════════════════════════════════════════

RESPIRATORY CASES

CASE 7 - Bronchial Asthma (Mild Persistent)

Patient: Mr. Ahmed K., 32 M, painter Chief Complaint: Episodic wheezing, breathlessness, nocturnal cough × 1 year History: Symptoms >2 days/week but not daily, nocturnal symptoms >2×/month. Uses Salbutamol inhaler PRN. Atopic (allergic rhinitis, eczema). No smoking. Examination:

RR: 18/min at rest
SpO₂: 98% at rest
Bilateral expiratory wheeze on auscultation during episode
PEF: 78% predicted

Investigations:

Spirometry: FEV1/FVC 68% (obstructive pattern)
Post-bronchodilator FEV1 increase: 15% (reversibility confirmed)
Skin prick test: Positive for house dust mite, pollen
CBC: Eosinophilia (8%)

Diagnosis: Bronchial Asthma - Mild Persistent (GINA Step 2)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Ahmed K.        Age: 32 M       Date: __/__/____
Dx: Bronchial Asthma (Mild Persistent, GINA Step 2)

Rx:
1. BUDESONIDE 200 mcg MDI          2 puffs BD      × 30 days
   (inhaled corticosteroid - controller therapy)
   Use spacer. Rinse mouth after each use.

2. SALBUTAMOL (Albuterol) 100 mcg MDI   2 puffs PRN
   (SABA - reliever; use when symptomatic)
   If using >2×/week, step up therapy

Advice:
• Demonstrate and check inhaler technique at each visit
• Avoid triggers: dust mites, cold air, paint fumes
• Allergen-proof mattress and pillow covers
• Asthma Action Plan provided (written)
• Avoid NSAIDs, beta-blockers (worsen asthma)

Review: 4-6 weeks
══════════════════════════════════════════════════

CASE 8 - COPD (Stable, Moderate)

Patient: Mr. Baldev S., 62 M, retired farmer, smoker 30 pack-years Chief Complaint: Progressive breathlessness, productive cough for 5 years History: Dyspnea on moderate exertion (mMRC Grade 2). Morning cough with whitish sputum. 2 exacerbations last year requiring antibiotics. Examination:

Barrel chest, reduced chest expansion
Hyper-resonant percussion
Reduced breath sounds bilaterally, prolonged expiration
SpO₂: 93% at rest
No cyanosis

Investigations:

Spirometry: FEV1 52% predicted, FEV1/FVC 58% (post-BD, no significant reversibility) - GOLD Grade II
CXR: Hyperinflation, flattened diaphragm
ABG: pH 7.38, PaO₂ 68 mmHg, PaCO₂ 46 mmHg
CBC: Polycythemia (Hb 17.2 g/dL)

Diagnosis: COPD - GOLD Group B (Moderate, High Symptom Burden)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Baldev S.       Age: 62 M       Date: __/__/____
Dx: COPD GOLD Group B (FEV1 52%, mMRC Grade 2)

Rx:
1. TIOTROPIUM 18 mcg HANDIHALER    1 capsule inhaled OD × 30 days
   (LAMA - long-acting muscarinic antagonist, first-line)

2. SALMETEROL/FLUTICASONE 
   (Seretide) 25/250 mcg MDI       2 puffs BD      × 30 days
   (LABA + ICS - add for persistent symptoms)

3. SALBUTAMOL 100 mcg MDI          2 puffs PRN
   (SABA - for rescue)

4. Tab. MUCOLYTIC (ERDOSTEINE 300mg) 1-0-1         × 15 days
   (during winter/symptomatic periods)

Advice:
• SMOKING CESSATION is the single most important intervention
• Annual influenza vaccine, pneumococcal vaccine
• Pulmonary rehabilitation referral
• Supplemental O₂ if SpO₂ drops <88%

Review: 3 months or sooner if exacerbation
══════════════════════════════════════════════════

CASE 9 - Community-Acquired Pneumonia (CAP, Outpatient)

Patient: Ms. Deepa T., 38 F, nurse Chief Complaint: Fever, cough with yellowish sputum, right-sided chest pain × 5 days History: Chills, rigors on day 1. Pleuritic chest pain. No TB exposure. Vaccinated. Examination:

Temp: 38.8°C, RR: 22/min, HR: 98, BP: 118/76
SpO₂: 96% on room air
Right lower zone: dullness to percussion, increased vocal fremitus, bronchial breath sounds

Investigations:

CBC: WBC 14,200 (neutrophilia)
CXR: Right lower zone consolidation
CRP: 64 mg/L
PSI (PORT) Score: Class II (low severity, outpatient management)
Sputum culture: Sent (Streptococcus pneumoniae expected)

Diagnosis: Community-Acquired Pneumonia (CAP) - Low Severity (Outpatient)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Ms. Deepa T.        Age: 38 F       Date: __/__/____
Dx: CAP (Low Severity, PORT Class II)

Rx:
1. Tab. AMOXICILLIN-CLAVULANATE 
   (Augmentin) 625 mg              1-0-1 × 7 days
   (covers S.pneumoniae, H.influenzae, atypicals partially)

   OR (if penicillin allergy):
   Tab. AZITHROMYCIN 500 mg        1-0-0 × 5 days

2. Tab. PARACETAMOL 650 mg         1-1-1 (for fever)  × 5 days

3. Syrup AMBROXOL 30 mg            1-1-1               × 5 days
   (mucolytic, expectorant)

4. Tab. IBUPROFEN 400 mg           1-0-1 after food    × 3 days
   (for pleuritic pain)

Advice:
• Increase fluid intake (2-3 L/day)
• Return IMMEDIATELY if SpO₂ <94%, RR >30, confusion
• Rest for 5-7 days
• Repeat CXR at 6 weeks to confirm resolution

Review: 48-72 hours to reassess
══════════════════════════════════════════════════

GASTROINTESTINAL CASES

CASE 10 - Gastroesophageal Reflux Disease (GERD)

Patient: Mr. Ravi N., 44 M, IT professional Chief Complaint: Heartburn, acid regurgitation after meals for 6 months, worse on bending/lying History: Late-night meals, high coffee intake, sedentary. No dysphagia, no weight loss. Examination:

BMI: 28, epigastric mild tenderness
No dysphagia, no hematemesis

Investigations:

Upper GI endoscopy: Grade B esophagitis (LA classification - breaks >5 mm, not confluent)
H. pylori rapid urease test: Negative
Barium swallow: Free gastro-esophageal reflux

Diagnosis: GERD with Erosive Esophagitis (LA Grade B)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Ravi N.         Age: 44 M       Date: __/__/____
Dx: GERD (Erosive, LA Grade B)

Rx:
1. Tab. PANTOPRAZOLE 40 mg         1-0-0 (30 min before breakfast)
   × 8 weeks
   (PPI - gold standard; heals esophagitis in 4-8 weeks)

2. Syrup MAGALDRATE + SIMETHICONE  10 mL after meals + at bedtime
   (antacid for symptomatic relief)

3. Tab. DOMPERIDONE 10 mg          1-1-1 (15 min before meals)
   × 4 weeks
   (prokinetic - reduces reflux episodes)

Advice:
• Elevate head of bed by 15-20 cm (use wedge, not extra pillows)
• Avoid coffee, chocolate, alcohol, mint, fatty foods, citrus
• No meals within 2-3 hours of bedtime
• Reduce weight (target BMI <25)
• Return if dysphagia, weight loss, hematemesis (red flags)

Review: 8 weeks (reassess need for long-term PPI)
══════════════════════════════════════════════════

Source: Sleisenger and Fordtran's Gastrointestinal and Liver Disease, GERD section

CASE 11 - Peptic Ulcer Disease (H. pylori positive)

Patient: Mrs. Fatima B., 50 F Chief Complaint: Epigastric pain relieved by food, nocturnal pain waking from sleep × 3 months History: Regular NSAID use for knee pain. Examination:

Epigastric tenderness on deep palpation
No guarding, no rebound
No signs of perforation

Investigations:

Endoscopy: 1.2 cm duodenal ulcer (D1), clean base
Rapid urease test (CLO test): Positive for H. pylori
Hb: 10.8 (mild anemia from occult blood loss)

Diagnosis: Duodenal Ulcer + H. pylori infection

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mrs. Fatima B.      Age: 50 F       Date: __/__/____
Dx: Duodenal Ulcer + H. pylori (CLO +ve)

Rx: (Triple Therapy - 14 days)
1. Tab. PANTOPRAZOLE 40 mg         1-0-1
2. Tab. CLARITHROMYCIN 500 mg      1-0-1
3. Tab. AMOXICILLIN 1 g            1-0-1
   ALL × 14 DAYS (standard triple therapy)

Then:
4. Tab. PANTOPRAZOLE 40 mg         1-0-0 × 4 more weeks
   (continue PPI after antibiotics for ulcer healing)

5. STOP NSAIDS. If essential:
   Tab. CELECOXIB 200 mg + PPI (safer)

6. Tab. FERROUS FUMARATE 200 mg    1-0-1 × 30 days
   (for anemia)

Advice:
• Test for H. pylori eradication 4 weeks AFTER completing antibiotics
  (13C-urea breath test or stool antigen test)
• Avoid alcohol, smoking, NSAIDs
• Eat small, frequent meals; avoid spicy food

Review: 6 weeks
══════════════════════════════════════════════════

CASE 12 - Irritable Bowel Syndrome (IBS-D)

Patient: Ms. Meena R., 29 F, accountant Chief Complaint: Alternating loose stools and constipation, bloating, abdominal cramps × 1 year History: Symptoms related to stress. No blood in stool, no fever, no weight loss. Symptoms often relieved after defecation. Examination:

Mild left iliac fossa tenderness
No organomegaly
Per rectal: No mass

Investigations:

CBC, CRP, ESR: Normal
Thyroid function: Normal
Stool routine/culture: Negative
Colonoscopy (Rome IV criteria met, alarm features absent, age <45): Deferred
Diagnosis: IBS-D (Diarrhea predominant, Rome IV criteria)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Ms. Meena R.        Age: 29 F       Date: __/__/____
Dx: IBS-D (Diarrhea predominant)

Rx:
1. Tab. MEBEVERINE 135 mg          1-0-1 (before meals) × 30 days
   (antispasmodic - first-line for pain/cramping)

2. Tab. LOPERAMIDE 2 mg            PRN (max 16 mg/day)
   (for acute diarrheal episodes only)

3. Cap. LACTOBACILLUS (VSL#3 or 
   Sporlac DS)                     1-0-1               × 30 days
   (probiotics - shown to reduce IBS symptoms)

4. Tab. ESCITALOPRAM 5 mg          1-0-0               × 30 days
   (low-dose SSRI for gut-brain axis; helps anxiety component)
   Titrate to 10 mg after 2 weeks if tolerated.

Advice:
• Low-FODMAP diet trial (reduce wheat, dairy, legumes, onion, garlic)
• Identify and manage psychological stressors
• Cognitive Behavioral Therapy (CBT) referral
• Keep a food-symptom diary

Review: 4 weeks
══════════════════════════════════════════════════

MUSCULOSKELETAL CASES

CASE 13 - Rheumatoid Arthritis (Early, Active)

Patient: Mrs. Anjali K., 42 F Chief Complaint: Bilateral hand joint pain and swelling, morning stiffness >1 hour × 8 months History: Symmetric small joint involvement, fatigue, low-grade fever. Examination:

Bilateral MCP and PIP joint swelling (tender, warm)
Morning stiffness: 90 minutes
No deformities yet (early disease)
DAS28 score: 4.8 (moderate disease activity)

Investigations:

RF: Positive (1:640)
Anti-CCP antibody: 85 U/mL (high positive - specific for RA)
CRP: 42 mg/L, ESR: 78 mm/hr
X-ray hands: Periarticular osteopenia, no erosions (early)
CBC: Hb 10.4 (anemia of chronic disease)

Diagnosis: Rheumatoid Arthritis (Early, Moderate Activity)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mrs. Anjali K.      Age: 42 F       Date: __/__/____
Dx: Rheumatoid Arthritis (Early, DAS28: 4.8)

Rx:
1. Tab. METHOTREXATE 7.5 mg        Once WEEKLY (Monday)    × 4 weeks
   (cDMARD - anchor drug; increase to 15 mg/wk in 4 weeks)

2. Tab. FOLIC ACID 5 mg            6 days/week (NOT on MTX day)
   (prevents MTX side effects: stomatitis, nausea, cytopenias)

3. Tab. HYDROXYCHLOROQUINE 200 mg  1-0-1                   × 30 days
   (combination DMARD therapy)

4. Tab. PREDNISOLONE 10 mg         1-0-0                   × 2 weeks
   then taper to 5 mg × 2 weeks then stop
   (bridge therapy while DMARDs take effect)

5. Tab. CALCIUM + VITAMIN D3
   (Shelcal-CT)                    1-0-1                   × 30 days
   (steroid-induced osteoporosis prevention)

Advice:
• Baseline: LFT, CBC, creatinine before MTX
• Monthly CBC + LFT while on MTX
• AVOID: alcohol (hepatotoxicity), NSAIDs (additive nephrotoxicity)
• Physiotherapy for hand exercises
• Ophthalmology baseline for hydroxychloroquine

Review: 4 weeks with labs
══════════════════════════════════════════════════

CASE 14 - Osteoarthritis (Knee)

Patient: Mr. Kiran B., 60 M, farmer Chief Complaint: Bilateral knee pain, worse on standing/climbing stairs, stiffness <30 min after rest × 2 years Examination:

Crepitus on knee flexion/extension
Bony enlargement (osteophytes) at knee margins
Mild effusion right knee
No warmth (cold joint)
Quadriceps wasting

Investigations:

X-ray knees: Joint space narrowing, osteophytes, subchondral sclerosis (K-L Grade III)
ESR, CRP: Normal
RA factor: Negative
Uric acid: 5.2 mg/dL

Diagnosis: Bilateral Primary Osteoarthritis Knee (K-L Grade III)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Kiran B.        Age: 60 M       Date: __/__/____
Dx: Osteoarthritis Knee (K-L Grade III)

Rx:
1. Tab. PARACETAMOL 650 mg         1-1-1 after food    × 14 days
   (first-line analgesic for OA, safest)

2. Tab. ETORICOXIB 60 mg           1-0-0 after food    × 14 days
   (COX-2 inhibitor: better GI profile than NSAIDs)
   Avoid if eGFR <30, cardiovascular disease

3. Cap. GLUCOSAMINE SULFATE 500 mg  1-1-1               × 90 days
   + CHONDROITIN 400 mg
   (may slow progression, modest pain relief)

4. DICLOFENAC 1% GEL (topical)     Apply to knee BD    × 30 days
   (topical NSAID: good local effect, minimal systemic effects)

5. INTRA-ARTICULAR HYALURONIC ACID (Durolane)
   × 3 injections (if conservative management fails)

Advice:
• Quadriceps strengthening exercises (physiotherapy)
• Swimming, cycling preferred over running/squatting
• Unloader knee brace for medial compartment disease
• Weight loss to reduce joint load
• Refer orthopedics if Grade IV or functional impairment for TKR

Review: 4 weeks
══════════════════════════════════════════════════

CASE 15 - Gout (Acute Attack)

Patient: Mr. Vijesh T., 52 M, businessman Chief Complaint: Sudden onset severe pain, redness, swelling right big toe since last night History: Ate red meat and alcohol 2 nights ago. Previous similar episode 1 year ago. Examination:

First MTP joint: Hot, red, exquisitely tender, swollen (classic podagra)
Temp: 37.8°C
BP: 146/90

Investigations:

Serum uric acid: 9.8 mg/dL (elevated)
Joint aspirate: Negatively birefringent needle-shaped crystals (monosodium urate)
WBC: 11,200 (mild leukocytosis)
X-ray foot: Soft tissue swelling only (early/acute)
Creatinine: 1.1 mg/dL

Diagnosis: Acute Gout (Podagra) - Acute Attack

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Vijesh T.       Age: 52 M       Date: __/__/____
Dx: Acute Gout (Podagra)

Rx: (Acute Attack - Phase 1):
1. Tab. INDOMETHACIN 50 mg         1-1-1 after food    × 5 days
   (NSAID of choice for acute gout; powerful anti-inflammatory)
   OR Tab. ETORICOXIB 120 mg OD × 5 days

2. Tab. COLCHICINE 0.5 mg          1-0-1               × 5 days
   (start within 24 hours of attack; very effective)
   AVOID if CrCl <10 mL/min

3. Tab. PANTOPRAZOLE 40 mg         1-0-0               × 5 days
   (GI protection with NSAID)

Phase 2 (Start 2-4 weeks AFTER acute attack resolves):
4. Tab. ALLOPURINOL 100 mg         1-0-0               × 30 days
   (urate-lowering therapy; NEVER start during acute attack)
   Titrate to 300 mg/day to target uric acid <6 mg/dL

Advice:
• Rest affected joint, elevate limb, ice pack
• Purine-restricted diet: avoid red meat, shellfish, organ meats
• Avoid alcohol (especially beer)
• Drink 2-3 L water daily
• Avoid aspirin, thiazide diuretics (raise uric acid)

Review: 2 weeks
══════════════════════════════════════════════════

NEUROLOGICAL CASES

CASE 16 - Migraine (Without Aura)

Patient: Ms. Pooja S., 26 F, student Chief Complaint: Recurrent severe one-sided throbbing headache × 2 years, 3-4 episodes/month History: Pain lasts 4-72 hours, associated with nausea, vomiting, photophobia, phonophobia. Worsens with activity. No visual aura. Family history (mother). Examination:

Normal neurological examination
No papilledema
No meningism

Investigations:

MRI brain: Normal (done to exclude secondary cause)
Diagnosis by ICHD-3 criteria (5+ attacks fulfilling criteria)

Diagnosis: Migraine Without Aura (ICHD-3)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Ms. Pooja S.        Age: 26 F       Date: __/__/____
Dx: Migraine Without Aura (3-4 attacks/month)

Rx: ACUTE (ABORTIVE) TREATMENT:
1. Tab. SUMATRIPTAN 50 mg          1 tablet at onset of attack
   May repeat after 2 hrs if recurrence (max 200 mg/24h)
   (triptan - gold standard for moderate-severe migraine)

2. Tab. DOMPERIDONE 10 mg          1-0-0 (with sumatriptan)
   (antiemetic + hastens gastric emptying for better absorption)

3. Tab. IBUPROFEN 400 mg           PRN (for mild attacks)

PREVENTIVE (given 3-4 attacks/month - threshold for prophylaxis):
4. Tab. PROPRANOLOL 40 mg          1-0-1               × 30 days
   (first-line migraine prophylaxis; titrate to 80-160 mg/day)
   AVOID in asthma

Advice:
• Headache diary: record triggers (sleep, stress, hormones, food)
• Avoid tyramine-rich foods, alcohol, caffeine excess
• Regular sleep schedule (irregular sleep is a major trigger)
• Avoid opioids (risk of medication overuse headache)
• Return if headache is worst ever, fever+neck stiffness, focal deficits

Review: 6 weeks
══════════════════════════════════════════════════

CASE 17 - Epilepsy (First Seizure, Generalized)

Patient: Mr. Arjun M., 24 M, college student Chief Complaint: First episode of generalized tonic-clonic seizure lasting ~2 minutes yesterday History: Post-ictal confusion for 30 min. No previous episodes. No head trauma, no family history. Examination:

Tongue bite, post-ictal (normal now)
Neurological exam: Normal
BP: 124/78

Investigations:

MRI brain with contrast: Normal
EEG: Generalized spike-wave discharges (2 Hz) - consistent with primary generalized epilepsy
Metabolic panel: Normal glucose, electrolytes
Drug/alcohol screen: Negative

Diagnosis: Generalized Epilepsy (Idiopathic)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Arjun M.        Age: 24 M       Date: __/__/____
Dx: Generalized Epilepsy

Rx:
1. Tab. SODIUM VALPROATE CR 500 mg  1-0-1               × 30 days
   (first-line for generalized epilepsy; teratogenic - caution in females)
   Titrate to 1000-2000 mg/day for seizure control

2. Tab. FOLIC ACID 5 mg            1-0-0               × ongoing
   (if female of childbearing age on valproate)

Advice:
• Do NOT stop medication abruptly
• No driving for 6 months (as per local regulations)
• Avoid alcohol, sleep deprivation (major seizure triggers)
• Monitor LFT, CBC at baseline and every 6 months
• Serum valproate level in 4 weeks (therapeutic: 50-100 mcg/mL)
• INFORM family about seizure first aid (lateral position, DO NOT restrain)

Review: 4 weeks
══════════════════════════════════════════════════

PSYCHIATRIC / PSYCHOSOMATIC CASES

CASE 18 - Major Depressive Disorder

Patient: Mrs. Lalitha P., 38 F Chief Complaint: Persistent low mood, loss of interest in activities, fatigue × 6 weeks History: Insomnia (early morning waking), poor appetite, weight loss 4 kg, difficulty concentrating, feelings of worthlessness. PHQ-9 score: 18 (moderately severe). Examination:

Psychomotor retardation
Flat affect
No suicidal ideation (screen negative with Columbia Suicide Severity Rating Scale)
Thyroid/metabolic exam: Normal

Investigations:

TSH: Normal (rule out hypothyroidism)
CBC, LFT, RFT: Normal
PHQ-9: 18 (moderately severe depression)

Diagnosis: Major Depressive Disorder (Moderate-Severe, single episode)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mrs. Lalitha P.     Age: 38 F       Date: __/__/____
Dx: Major Depressive Disorder (PHQ-9: 18)

Rx:
1. Tab. ESCITALOPRAM 10 mg         1-0-0 (morning)     × 30 days
   (SSRI - first-line; full effect in 4-6 weeks)
   May increase to 20 mg after 4 weeks if needed

2. Tab. CLONAZEPAM 0.5 mg          0-0-1               × 2 weeks only
   (short-term for severe insomnia/anxiety; avoid long-term use)

Advice:
• Psychotherapy (CBT) referral strongly recommended
• Full course required: minimum 6-9 months
• Do NOT stop medication abruptly (discontinuation syndrome)
• Exercise 30 min daily (proven antidepressant effect)
• Suicidal ideation: go to ER immediately
• Side effects: Initial nausea/insomnia improves in 1-2 weeks

Review: 2 weeks (then monthly)
══════════════════════════════════════════════════

CASE 19 - Generalized Anxiety Disorder (GAD)

Patient: Mr. Rohit K., 31 M, marketing manager Chief Complaint: Excessive worry about work/finances, restlessness, muscle tension, poor sleep × 6 months History: Difficulty controlling worry, irritable, can't concentrate. GAD-7 score: 14 (moderate). Examination:

Mildly elevated BP (138/88), tachycardia (HR 96)
Physical examination otherwise normal
No thyroid enlargement

Investigations:

TSH: Normal, CBC: Normal
ECG: Sinus tachycardia, no arrhythmia
GAD-7: 14 (moderate)

Diagnosis: Generalized Anxiety Disorder (DSM-5)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Rohit K.        Age: 31 M       Date: __/__/____
Dx: Generalized Anxiety Disorder (GAD-7: 14)

Rx:
1. Tab. SERTRALINE 50 mg           1-0-0 (with food)   × 30 days
   (SSRI - first-line for GAD)

2. Tab. BUSPIRONE 10 mg            1-0-1               × 30 days
   (non-benzodiazepine anxiolytic; take 2-4 weeks for effect)

Advice:
• CBT is as effective as medications - refer
• Avoid benzodiazepines for long-term use (dependence)
• Mindfulness-based stress reduction (MBSR) techniques
• Limit caffeine, alcohol
• Exercise regularly
• Sleep hygiene education

Review: 4 weeks
══════════════════════════════════════════════════

UROLOGICAL / NEPHROLOGY CASES

CASE 20 - Urinary Tract Infection (Uncomplicated, Female)

Patient: Ms. Ananya G., 22 F, college student Chief Complaint: Burning micturition, frequency, urgency × 2 days History: No fever, no loin pain, no vaginal discharge. Sexually active. No previous UTI. Examination:

Suprapubic tenderness
No costovertebral angle tenderness (no pyelonephritis)
Temp: 37.1°C

Investigations:

Urine R/E: Pyuria (>10 WBC/HPF), bacteria +++
Urine culture: E. coli >10⁵ CFU/mL (sent before starting antibiotics)
Pregnancy test: Negative

Diagnosis: Uncomplicated Cystitis (UTI)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Ms. Ananya G.       Age: 22 F       Date: __/__/____
Dx: Uncomplicated UTI (Acute Cystitis)

Rx:
1. Tab. NITROFURANTOIN 100 mg MR   1-0-1 with food     × 5 days
   (first-line, high urinary concentration, low resistance)

   OR Tab. TRIMETHOPRIM 200 mg     1-0-1               × 3 days
   (if local resistance <20%)

   OR Tab. FOSFOMYCIN 3g           Single dose
   (single dose regimen, excellent compliance)

2. Tab. PHENAZOPYRIDINE 200 mg     1-1-1 × 2 days only
   (urinary analgesic - relieves burning urgency quickly)
   WARN: turns urine orange-red (not blood)

3. Tab. PARACETAMOL 500 mg         PRN for pain

Advice:
• Complete full antibiotic course
• Drink 2-3 L water daily
• Urinate after sexual intercourse
• Wipe front to back
• Return if fever develops, loin pain (possible pyelonephritis)

Review: 5 days (with culture and sensitivity report)
══════════════════════════════════════════════════

CASE 21 - Benign Prostatic Hyperplasia (BPH)

Patient: Mr. Narayana R., 67 M Chief Complaint: Weak urinary stream, hesitancy, nocturia × 2, incomplete emptying × 18 months History: IPSS (International Prostate Symptom Score): 18 (moderate) Examination:

DRE (Digital Rectal Exam): Smooth, enlarged prostate (~40 mL), non-tender, no hard nodules
No pedal edema

Investigations:

PSA: 2.8 ng/mL (slightly elevated; age-adjusted normal)
USG abdomen: Prostate 42 mL, post-void residual 110 mL
Creatinine: 1.0 (no obstructive uropathy)
Urine culture: Sterile

Diagnosis: Benign Prostatic Hyperplasia (Moderate LUTS)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Narayana R.     Age: 67 M       Date: __/__/____
Dx: BPH (IPSS 18, prostate 42 mL)

Rx:
1. Tab. TAMSULOSIN 0.4 mg          0-0-1 (after dinner) × 30 days
   (alpha-1 blocker: relaxes prostate/bladder neck smooth muscle)
   Side effect: retrograde ejaculation, orthostatic hypotension

2. Tab. FINASTERIDE 5 mg           0-0-1               × 30 days
   (5-alpha reductase inhibitor: shrinks prostate; takes 3-6 months)
   Combined alpha-blocker + 5ARI: better for large prostates

Advice:
• Avoid: alcohol, coffee, cold medicines (decongestants worsen symptoms)
• Limit fluids in evenings, empty bladder before bed
• Annual PSA monitoring
• Urology referral if PSA rising, post-void residual >300 mL, recurrent UTI
• Side effect: Finasteride causes decreased libido, impotence in ~4%

Review: 3 months with repeat IPSS + PSA
══════════════════════════════════════════════════

HEMATOLOGICAL CASES

CASE 22 - Iron Deficiency Anemia

Patient: Mrs. Rekha S., 30 F, housewife Chief Complaint: Fatigue, pallor, breathlessness on exertion, craving to eat clay × 2 months History: Menorrhagia (heavy periods, 7-8 days), 3 pregnancies, poor diet. Examination:

Pallor (conjunctival, palmar, mucosal)
Koilonychia (spoon-shaped nails)
Angular stomatitis, glossitis
HR: 102 bpm, no cardiac murmur

Investigations:

Hb: 7.8 g/dL
MCV: 64 fL (microcytic), MCH: 18 pg (hypochromic)
Serum ferritin: 6 ng/mL (very low; most specific for iron deficiency)
Serum iron: 42 mcg/dL (low), TIBC: 480 mcg/dL (high)
Peripheral smear: Microcytic hypochromic RBCs, pencil cells, target cells

Diagnosis: Iron Deficiency Anemia (severe) due to Menorrhagia

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mrs. Rekha S.       Age: 30 F       Date: __/__/____
Dx: Iron Deficiency Anemia (Hb 7.8, Ferritin 6)

Rx:
1. Tab. FERROUS SULFATE 200 mg     1-0-1 (empty stomach or with juice)
   × 90 days
   (provides 60 mg elemental iron/tablet; continue 3 months
    after Hb normalizes to replenish stores)

2. Tab. VITAMIN C 500 mg           1-0-1 (WITH iron tablet)
   (enhances iron absorption by 30%)

3. Tab. FOLIC ACID 5 mg            1-0-0               × 90 days

Gynaecology referral for menorrhagia management:
4. Tab. TRANEXAMIC ACID 500 mg     1-1-1 during periods × 5 days
   (antifibrinolytic to reduce menstrual blood loss)

Advice:
• Iron: take 1 hour before or 2 hours after meals
• Avoid with tea, coffee, milk (inhibit absorption)
• Black/dark stools - normal with iron therapy
• Expected Hb rise: 1-2 g/dL per week
• Reticulocyte count peaks at day 7-10 (confirms response)

Review: 4 weeks with CBC
══════════════════════════════════════════════════

CASE 23 - Vitamin B12 Deficiency (Megaloblastic Anemia)

Patient: Mr. Thomas V., 55 M, strict vegetarian Chief Complaint: Fatigue, tingling/numbness in hands and feet, difficulty walking × 1 year History: Strict vegan diet for 10 years. No GI surgery. Mild memory issues. Examination:

Pallor, lemon-yellow tinge to skin
Glossitis (beefy red tongue)
Loss of vibration sense and proprioception (posterior column signs)
Romberg's test: Positive

Investigations:

Hb: 8.6 g/dL, MCV: 112 fL (macrocytic)
Peripheral smear: Macro-ovalocytes, hypersegmented neutrophils (>5 lobes)
Serum B12: 78 pg/mL (low; Normal >200 pg/mL)
Serum folate: Normal
Homocysteine: Elevated (68 mcmol/L)
Intrinsic factor antibodies: Sent

Diagnosis: Vitamin B12 Deficiency (Megaloblastic Anemia + Subacute Combined Degeneration)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Thomas V.       Age: 55 M       Date: __/__/____
Dx: B12 Deficiency Anemia + Neurological involvement

Rx:
1. Inj. CYANOCOBALAMIN (B12) 1000 mcg IM
   Daily × 7 days, then weekly × 4 weeks,
   then monthly for life
   (IM route essential if neurological involvement or pernicious anemia)

   After loading:
2. Tab. METHYLCOBALAMIN 1500 mcg   1-0-0               × ongoing
   (oral maintenance for dietary deficiency without pernicious anemia)

3. Tab. FOLIC ACID 5 mg            1-0-0               × 30 days
   (ALWAYS give B12 first before folate to avoid masking 
    B12 deficiency and worsening neuropathy)

4. Cap. PREGABALIN 75 mg           0-0-1               × 30 days
   (for neuropathic pain/tingling)

Advice:
• Neurological recovery: months to years; Hb normalizes in 6-8 weeks
• Reticulocyte crisis at day 7-10 (expected, good sign)
• Dietary B12 sources: meat, eggs, dairy, fortified cereals
• Lifelong supplementation if pernicious anemia confirmed

Review: 4 weeks with CBC
══════════════════════════════════════════════════

DERMATOLOGICAL CASES

CASE 24 - Psoriasis (Plaque Type, Mild-Moderate)

Patient: Mr. Manish G., 35 M Chief Complaint: Scaly, itchy red patches on elbows, knees, scalp × 3 years History: Family history (father). Exacerbated by stress, streptococcal throat infections. Nail pitting noted. Examination:

Well-demarcated erythematous plaques with silvery-white scales on extensor surfaces
Auspitz sign: Positive (pinpoint bleeding on scale removal)
Nail changes: Pitting, onycholysis
PASI score: 8 (moderate)
No joint involvement

Investigations:

Clinical diagnosis (biopsy if atypical: parakeratosis, acanthosis, Munro microabscesses)
ASO titer: 320 (recent strep infection trigger)
Throat swab: Group A Streptococcus

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Manish G.       Age: 35 M       Date: __/__/____
Dx: Plaque Psoriasis (PASI 8, moderate)

Rx:
1. CALCIPOTRIOL 0.005% ointment    Apply BD to plaques  × 4 weeks
   (vitamin D analog - first-line topical)

2. BETAMETHASONE DIPROPIONATE 0.05% ointment
   Apply OD (evenings)            × 2 weeks
   (potent topical steroid; limited use to avoid atrophy)
   COMBINATION (Daivobet = calcipotriol + betamethasone) is more effective

3. SALICYLIC ACID 6% ointment      Apply to thick plaques OD × 2 weeks
   (keratolytic - softens scale before steroid)

4. For scalp psoriasis:
   CLOBETASOL PROPIONATE 0.05% shampoo/lotion
   Apply to scalp, leave 15 min, wash × alternate days

5. Tab. CETIRIZINE 10 mg           0-0-1               × 30 days
   (for pruritus)

6. EMOLLIENT (white soft paraffin/Vaseline) apply frequently
   (moisturize to prevent fissuring)

Advice:
• Avoid scratching (Koebner phenomenon - new lesions at trauma sites)
• Sun exposure in moderation (beneficial for psoriasis)
• Stress management
• Dermatology referral if PASI >10 or not responding
  (systemic therapy: methotrexate, cyclosporine, biologics)

Review: 4 weeks
══════════════════════════════════════════════════

CASE 25 - Acne Vulgaris (Moderate)

Patient: Ms. Shruti R., 19 F, college student Chief Complaint: Facial acne, blackheads, painful pimples × 2 years, worsening perimenstrually History: Oily skin. Previous use of OTC benzoyl peroxide with partial response. Examination:

Comedones (open + closed), inflammatory papules, pustules on face, chest, back
Few nodules on jaw line
No cysts/scars (not severe)
GAGS (Global Acne Grading Score): 24 (moderate)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Ms. Shruti R.       Age: 19 F       Date: __/__/____
Dx: Acne Vulgaris (Moderate, GAGS 24)

Rx:
1. ADAPALENE 0.1% gel               Apply to entire face ON   × 8 weeks
   (retinoid - unclogs pores, reduces comedones)
   Apply at night, use sunscreen in morning

2. CLINDAMYCIN 1% + BENZOYL 
   PEROXIDE 5% gel (Duac/Epiduo)   Apply BD                  × 8 weeks
   (topical antibiotic + BPO: prevents resistance)

3. Tab. DOXYCYCLINE 100 mg          1-0-0 after food          × 6 weeks
   (oral antibiotic for inflammatory acne)
   Take with water, remain upright for 30 min (avoid esophagitis)
   Avoid sun exposure (photosensitivity)

4. Tab. CYPROTERONE/ETHINYL 
   ESTRADIOL (Diane-35)             1-0-0 (if on contraception, 
                                    hormonal acne in females)
   (anti-androgenic OCP for perimenstrual flares)

Advice:
• Gentle non-comedogenic face wash BD
• Oil-free, non-comedogenic moisturizer + SPF 30 sunscreen
• Do NOT squeeze/pick lesions (scarring)
• Full response takes 8-12 weeks; do not abandon treatment early
• If not improving in 3 months - refer to dermatologist for isotretinoin

Review: 8 weeks
══════════════════════════════════════════════════

OPHTHALMOLOGICAL / ENT CASES

CASE 26 - Allergic Rhinitis (Perennial)

Patient: Mr. Sanjay K., 28 M, teacher Chief Complaint: Nasal congestion, sneezing, runny nose, itchy eyes throughout the year × 3 years History: Worse at home (dust mites). Atopic (also has mild asthma). No polyps on previous scoping. Examination:

Pale, boggy nasal mucosa
Allergic shiners (dark circles under eyes)
Transverse nasal crease (salute sign)
Anterior rhinoscopy: Clear discharge, no polyps

Investigations:

Skin prick test: Positive for house dust mite, Aspergillus
IgE total: 480 IU/mL (high)
Nasal smear: Eosinophilia

Diagnosis: Perennial Allergic Rhinitis (Moderate-Severe, ARIA classification)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Sanjay K.       Age: 28 M       Date: __/__/____
Dx: Perennial Allergic Rhinitis (Moderate-Severe)

Rx:
1. MOMETASONE FUROATE (Nasonex) 50 mcg nasal spray
   2 sprays each nostril OD       × 30 days
   (intranasal corticosteroid - most effective single agent;
    onset: 1-2 weeks)

2. Tab. FEXOFENADINE 180 mg        1-0-0               × 30 days
   (non-sedating antihistamine for itching, sneezing)

3. OLOPATADINE 0.1% eye drops      1 drop each eye BD  × 30 days
   (for allergic conjunctivitis)

4. NASAL SALINE IRRIGATION (Neti pot / SinuRinse)
   BD                                                  × ongoing
   (washes out allergens from nasal mucosa)

Advice:
• Allergen-proof mattress and pillow covers
• Regular vacuuming with HEPA filter
• Avoid pets (if allergic)
• Consider sublingual immunotherapy if inadequate response
• ENT referral to exclude nasal polyps / deviated septum

Review: 4 weeks
══════════════════════════════════════════════════

CASE 27 - Acute Pharyngotonsillitis

Patient: Ms. Nandini P., 22 F Chief Complaint: Sore throat, fever, difficulty swallowing × 3 days History: No cough. Exposure to a friend with similar illness. Examination:

Temp: 38.6°C
Tonsils: Enlarged (Grade III), erythematous, white exudate on tonsils
Tender anterior cervical lymphadenopathy
No cough
Centor Score: 4 (exudate + tender nodes + fever + no cough = high probability Group A Strep)

Investigations:

Rapid Strep Antigen Test: Positive
Monospot test: Negative (exclude EBV mononucleosis)
CBC: WBC 14,500 (neutrophilia)

Diagnosis: Streptococcal Tonsillitis (Group A Beta-haemolytic Streptococcus)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Ms. Nandini P.      Age: 22 F       Date: __/__/____
Dx: Streptococcal Tonsillitis (Centor 4, Rapid Strep +)

Rx:
1. Tab. AMOXICILLIN 500 mg         1-1-1 × 10 days
   (first-line: must complete full 10 days to prevent 
    rheumatic fever)

   If penicillin allergy:
   Tab. AZITHROMYCIN 500 mg OD × 5 days

2. Tab. PARACETAMOL 650 mg         1-1-1 × 5 days
   (fever and pain relief)

3. Tab. IBUPROFEN 400 mg           1-0-1 after food    × 5 days
   (reduces tonsillar inflammation)

4. BENZYDAMINE (Tantum Verde) 
   gargle / spray                  Use every 3-4 hours
   (local anti-inflammatory gargle)

Advice:
• Warm salt water gargles
• Soft/liquid diet, good hydration
• Complete antibiotic course even if feeling better
• Contact precautions: cover mouth, separate utensils
• Return if unable to swallow/drool, trismus, muffled voice
  (peritonsillar abscess - emergency)

Review: 5 days if not improving
══════════════════════════════════════════════════

ORTHOPEDIC CASES

CASE 28 - Low Back Pain (Non-specific, Acute)

Patient: Mr. Deepak S., 40 M, software developer Chief Complaint: Sudden-onset lower back pain since bending to pick up object yesterday; pain 7/10 History: No radiation to legs, no neurological symptoms. Sedentary desk job. First episode. Red flag screen: No fever, no weight loss, no bladder/bowel dysfunction, no night pain, no trauma. Examination:

Lumbar muscle spasm, tenderness over L4-L5 paravertebral muscles
Forward flexion limited (pain)
SLR (Straight Leg Raise): Negative bilaterally
Normal lower limb neurology

Investigations:

X-ray lumbosacral spine: No fracture, mild lumbar spondylosis
(MRI NOT indicated in absence of red flags for first episode <6 weeks)

Diagnosis: Acute Non-Specific Low Back Pain

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Deepak S.       Age: 40 M       Date: __/__/____
Dx: Acute Non-Specific Low Back Pain

Rx:
1. Tab. IBUPROFEN 400 mg           1-1-1 after food    × 7 days
   (NSAID - first-line for acute LBP)

2. Tab. THIOCOLCHICOSIDE 4 mg      1-0-1               × 5 days
   (muscle relaxant for spasm; do not drive)

3. Tab. PANTOPRAZOLE 40 mg         1-0-0               × 7 days
   (GI protection with NSAID)

4. DICLOFENAC SODIUM EMULGEL 1%    Apply to lower back BD-TDS
   (topical NSAID)

Advice:
• Bed rest NOT recommended (active movement heals faster)
• Continue light activity as tolerated
• Hot pack application to lower back
• McKenzie exercises (physiotherapy)
• Ergonomic assessment of workstation
• Most acute LBP resolves in 4-6 weeks
• Return if numbness/weakness in legs, bladder/bowel changes

Review: 2 weeks
══════════════════════════════════════════════════

INFECTIOUS DISEASE CASES

CASE 29 - Pulmonary Tuberculosis (New Case)

Patient: Mr. Sami A., 30 M, migrant worker Chief Complaint: Cough >3 weeks, hemoptysis, evening fever, night sweats, weight loss × 2 months History: Close contact with TB patient (room-mate). Non-smoker. Examination:

Wasted, pale
Temp: 37.9°C (evening)
Right upper zone: Dullness, crepitations
Weight: 52 kg (BMI 17.8)

Investigations:

Sputum AFB smear: 3+ (highly positive)
GeneXpert MTB/RIF: MTB detected, Rifampicin sensitive
CXR: Right upper lobe fibro-cavitary infiltrates
HIV test: Negative (mandatory co-testing)
LFT: Normal (baseline before starting HRZE)
Uric acid: 5.1 mg/dL (baseline for pyrazinamide)

Diagnosis: Pulmonary TB (Sputum Positive, New Case, Drug-Sensitive)

══════════════════════════════════════════════════
     OUTPATIENT DEPARTMENT PRESCRIPTION
══════════════════════════════════════════════════
Pt: Mr. Sami A.         Age: 30 M  Wt: 52 kg   Date: __/__/____
Dx: Pulmonary TB (SS+, New Case)

Rx: (As per WHO/RNTCP 2022 guidelines)

INTENSIVE PHASE (2 months): HRZE
1. Tab. ISONIAZID (H) 300 mg       OD (fasting)
2. Tab. RIFAMPICIN (R) 450 mg      OD (fasting, <50 kg)
3. Tab. PYRAZINAMIDE (Z) 1500 mg   OD
4. Tab. ETHAMBUTOL (E) 800 mg      OD
   [All 4 drugs given as fixed-dose combination: 4-drug FDC tablet]

5. Tab. PYRIDOXINE (B6) 25 mg      OD
   (prevents INH-induced peripheral neuropathy)

CONTINUATION PHASE (4 months): HR
6. Tab. ISONIAZID 300 mg           OD
7. Tab. RIFAMPICIN 450 mg          OD
   (2-drug FDC for 4 months)

Advice:
• Notify health authorities (notifiable disease)
• Daily observed therapy (DOT) preferred
• Isolate until sputum smear negative
• Contact tracing: household contacts for LTBI
• WARN: rifampicin turns urine/secretions orange-red (normal)
• Monthly LFT monitoring; stop if bilirubin/enzymes rise >3x ULN
• No alcohol (hepatotoxicity)

Review: Monthly with sputum AFB, LFT
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GERIATRIC / MULTIMORBIDITY CASE

CASE 30 - Polypharmacy / Multimorbidity Review (Elderly Patient)

Patient: Mr. Krishnamurthy R., 72 M Chief Complaint: Follow-up for multiple conditions; dizziness, fall last week History: T2DM, HTN, hypothyroidism, GERD, knee OA, benign prostate, depression. Current Medications (brought to clinic): Metformin, Glibenclamide, Amlodipine, Enalapril, Levothyroxine, Omeprazole, Diclofenac, Tamsulosin, Alprazolam Examination:

BP lying: 138/80; Standing: 108/68 (orthostatic hypotension - cause of falls)
HR: 58 bpm
Postural sway on Romberg's

Issues identified (Medication Review using Beers Criteria 2023):

Glibenclamide - HIGH RISK in elderly (prolonged hypoglycemia) - STOP
Diclofenac - HIGH RISK in elderly (GI bleed, renal impairment, fluid retention) - STOP
Alprazolam - HIGH RISK in elderly (falls, cognitive impairment) - TAPER and STOP
Enalapril + Tamsulosin + Amlodipine - triple antihypertensive contributing to orthostatic hypotension
Omeprazole long-term - consider stopping/stepping down if no active GERD

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     OUTPATIENT DEPARTMENT PRESCRIPTION
     (Polypharmacy Review / Medication Optimization)
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Pt: Mr. Krishnamurthy R.  Age: 72 M    Date: __/__/____
Dx: Multimorbidity + Polypharmacy + Falls Risk

STOP:
- GLIBENCLAMIDE → Replace with Tab. SITAGLIPTIN 100 mg OD
  (safer DPP-4i in elderly, no hypoglycemia risk)
- DICLOFENAC → Replace with PARACETAMOL 500 mg + TOPICAL NSAID
- ALPRAZOLAM → Taper: halve dose every 2 weeks then stop
  Replace with Tab. MIRTAZAPINE 7.5 mg nocte
  (treats depression + improves sleep, no falls risk)

CONTINUE:
- Tab. METFORMIN 500 mg BD
- Tab. AMLODIPINE 5 mg OD
- Tab. LEVOTHYROXINE 50 mcg OD (morning, fasting)
- Tab. TAMSULOSIN 0.4 mg OD (for BPH)

REDUCE RISK:
- REDUCE ENALAPRIL to 5 mg (from 10 mg) to address orthostatic hypotension
- Tab. RABEPRAZOLE 20 mg OD only 3 days/week (PRN stepping down)

ADD:
- Tab. CALCIUM 500 mg + VITAMIN D3 1000 IU  OD
- FALL PREVENTION: home assessment, grab rails, night light

Advice:
• Medication reconciliation list given to patient and family
• Falls risk assessment
• Physiotherapy + balance training
• Re-check BP lying and standing in 2 weeks
• Brown bag review every 6 months

Review: 2 weeks
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QUICK REFERENCE SUMMARY TABLE

#	Case	Key Drug Class	Key Drug	Duration
1	Hypertension Stage 1	CCB	Amlodipine 5 mg	Long-term
2	HTN + DM + Nephropathy	ARB	Telmisartan 40 mg	Long-term
3	Stable Angina	Beta-blocker + Nitrate	Atenolol + ISDN	Long-term
4	T2DM (new)	Biguanide + SGLT2i	Metformin + Empagliflozin	Long-term
5	Hypothyroidism	Thyroid hormone	Levothyroxine 50 mcg	Lifelong
6	Graves' Disease	Antithyroid	Carbimazole 20 mg	12-18 months
7	Asthma (mild persistent)	ICS + SABA	Budesonide + Salbutamol	Long-term
8	COPD (moderate)	LAMA + LABA/ICS	Tiotropium + Salmeterol/Fluticasone	Long-term
9	Pneumonia (CAP, outpatient)	Aminopenicillin	Amoxicillin-Clavulanate	7 days
10	GERD (erosive)	PPI	Pantoprazole 40 mg	8 weeks
11	Peptic Ulcer + H. pylori	Triple therapy	PPI + Clarithromycin + Amoxicillin	14 days
12	IBS-D	Antispasmodic	Mebeverine 135 mg	30 days
13	Rheumatoid Arthritis	cDMARD	Methotrexate + Hydroxychloroquine	Long-term
14	Osteoarthritis Knee	COX-2 inhibitor	Etoricoxib 60 mg	Short courses
15	Gout (acute)	NSAID + Colchicine	Indomethacin + Colchicine	5 days acute
16	Migraine	Triptan	Sumatriptan 50 mg	PRN
17	Epilepsy (generalized)	Anticonvulsant	Sodium Valproate CR 500 mg	Long-term
18	Depression (MDD)	SSRI	Escitalopram 10 mg	6-9 months
19	Anxiety (GAD)	SSRI	Sertraline 50 mg	6-12 months
20	UTI (uncomplicated)	Nitrofurantoin	Nitrofurantoin 100 mg MR	5 days
21	BPH	Alpha-blocker + 5-ARI	Tamsulosin + Finasteride	Long-term
22	Iron Deficiency Anemia	Iron supplement	Ferrous Sulfate 200 mg	90 days
23	B12 Deficiency	Cobalamin	Cyanocobalamin IM 1000 mcg	Lifelong
24	Psoriasis (plaque)	Vitamin D analog	Calcipotriol 0.005% oint.	4 weeks
25	Acne Vulgaris (moderate)	Retinoid + Antibiotic	Adapalene + Doxycycline	6-8 weeks
26	Allergic Rhinitis	Intranasal steroid	Mometasone nasal spray	Long-term
27	Streptococcal Tonsillitis	Penicillin	Amoxicillin 500 mg	10 days
28	Low Back Pain (acute)	NSAID + Muscle relaxant	Ibuprofen + Thiocolchicoside	7 days
29	Pulmonary TB	HRZE regimen	4-drug FDC	6 months
30	Polypharmacy (elderly)	Medication review	De-prescribing (Beers criteria)	Ongoing

KEY PRESCRIBING PRINCIPLES (OPD Practice)

1. Before writing any prescription:

Check allergies and document
Check renal function (eGFR) before NSAIDs, metformin, methotrexate, nitrofurantoin
Check LFT before hepatotoxic drugs (methotrexate, anti-TB, statins)
Pregnancy status before tetracyclines, retinoids, warfarin, valproate, methotrexate

2. Prescription format essentials:

Drug name (generic preferred), dose, route, frequency, duration
Special instructions (empty stomach, after food, at night, with water)
Specific warnings (driving, photosensitivity, colour changes in urine)
Review date

3. Red flag symptoms requiring urgent referral:

System	Red Flags
GI	Dysphagia, hematemesis, weight loss, jaundice
Respiratory	Hemoptysis, SpO₂ <94%, stridor
Cardiovascular	Chest pain at rest, severe hypertension (>180/120)
Neurological	First/worst ever headache, focal deficits, altered consciousness
Musculoskeletal	Night pain, weight loss with bone pain, pathological fracture

4. Monitoring schedule for common drugs:

Drug	Monitoring
Metformin	Creatinine annually (hold if eGFR <30)
Methotrexate	CBC + LFT monthly
Carbimazole	CBC + TFT 4-6 weekly (watch for agranulocytosis)
Levothyroxine	TSH every 6 weeks until stable, then annually
Anti-TB drugs (HRZE)	LFT, uric acid (PZA), visual acuity (ethambutol) monthly
ACE inhibitors/ARBs	Creatinine + K+ in 2 weeks after starting
Sodium Valproate	LFT, CBC, drug levels every 6 months

Sources: Goldman-Cecil Medicine (International Edition), Textbook of Family Medicine 9e (Rakel), Katzung Basic & Clinical Pharmacology 16e, Sleisenger & Fordtran's Gastrointestinal & Liver Disease, WHO Essential Medicines guidelines, ACC/AHA 2017 HTN Guidelines, GINA 2023, GOLD 2024, ADA 2024, RNTCP/WHO TB guidelines 2022.

---Here is a complete summary of what was covered:

What You Got: 30 Adult OPD Cases for Practice & Education

All 30 cases include: Patient demographics → Chief complaint → History → Physical examination → Investigations with results → Diagnosis → Sample prescription → Patient advice → Review schedule

Cases by System:

System	Cases
Cardiovascular	Stage 1 HTN, Stage 2 HTN + DM + Nephropathy, Stable Angina
Endocrine	T2DM (new), Hypothyroidism, Hyperthyroidism (Graves')
Respiratory	Bronchial Asthma (GINA Step 2), COPD (GOLD B), Community-Acquired Pneumonia
Gastrointestinal	GERD (erosive), Peptic Ulcer + H. pylori, IBS-D
Musculoskeletal	Rheumatoid Arthritis, Osteoarthritis Knee, Acute Gout
Neurology	Migraine, Epilepsy (generalized)
Psychiatry	Major Depressive Disorder, Generalized Anxiety Disorder
Urology/Nephrology	Uncomplicated UTI, Benign Prostatic Hyperplasia
Hematology	Iron Deficiency Anemia, Vitamin B12 Deficiency
Dermatology	Plaque Psoriasis, Acne Vulgaris (moderate)
ENT	Allergic Rhinitis, Streptococcal Tonsillitis
Orthopedics	Acute Low Back Pain
Infectious Disease	Pulmonary Tuberculosis
Geriatrics	Polypharmacy/Medication Review (Beers Criteria)

Each prescription follows real-world format with drug name, dose, frequency, duration, and critical counselling points. A monitoring table and red flag reference guide are included at the end for quick OPD use.

I want this for practice and education purpose so mention details also

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