This is the details of a patient field in this sheet by a rmo explain every section in detial with the explanation of things field in this
Reading File
I can see the full patient record clearly in the images. Let me break down every section in detail.
In-Patient History and Physical Record - Complete Breakdown
HOSPITAL HEADER
Holy Heart Super Speciality & Trauma Centre, Rohtak - this is a NABH-accredited hospital (National Accreditation Board for Hospitals - India's quality certification for healthcare). The NABH logo confirms the hospital meets national patient safety and quality standards.
PATIENT IDENTIFICATION BLOCK (Top Right)
| Field | Value | Explanation |
|---|---|---|
| Patient Name | Mrs. Rekha | Full name of the admitted patient |
| UHID No. | 151465 | Unique Hospital ID - a permanent number assigned to this patient in the hospital system across all visits |
| IPD No. | 44067 | In-Patient Department number - assigned specifically for this admission episode |
| Age/Sex | 40 Y / Female | 40-year-old female |
| Admit Dt./Tim | 11/Jun/2025, 9:28 | Date and time of formal admission registration |
| Consultant | Dr. Shashi Chauhan | The specialist doctor responsible for this patient's care |
| Mobile No. | 8950161751 | Contact number (likely the consultant's or patient's for communication) |
ADMISSION DETAILS BLOCK
| Field | Value | Explanation |
|---|---|---|
| Unit | 304 | The ward or room number where the patient is admitted |
| Admission Type | Direct Admission / Shifted from Triage | This patient was directly admitted (not shifted from triage). Direct admission means the consultant pre-arranged the bed. |
| Date & Time of Admission | 11/6/26 | June 11, 2026 |
| Time of Arrival | 9:35 AM | When the patient physically arrived at the hospital |
| Consultant | Dr. Shashi | Same as above - the admitting consultant |
| Time of Assessment | 9:45 AM | When the RMO first evaluated the patient - 10 minutes after arrival (good response time) |
| Source of History | Self | The history was given by the patient herself (not a relative or bystander), meaning she is conscious and coherent |
| Speciality | Gynae | Gynaecology - the department under which she is admitted |
| Name of Dr. Taking History | RMO | Resident Medical Officer - the on-duty doctor who initially assessed and documented the case before the consultant reviewed |
SECTION A - CHIEF COMPLAINTS
Written:
P/L - Both NVD, Pain Abdomen, RPV, c/k/oExplanation of abbreviations:
- P/L - Per Labour (labour-related complaints) OR possibly Per Local (local per vaginal findings)
- Both NVD - Normal Vaginal Deliveries on both sides (likely indicating prior obstetric history contributing to current symptoms) - or this may refer to bilateral findings
- Pain Abdomen - Abdominal pain, one of the main presenting complaints
- RPV - Retained Products of conception, OR could be per vaginal discharge/bleeding
- c/k/o - A case known of - meaning the patient is already a diagnosed case of the condition listed (connects to the diagnosis of fibroids)
What this tells us: This 40-year-old woman presented with abdominal pain and likely per vaginal bleeding, and she is a known case of a pre-existing condition (uterine fibroid, as seen in the diagnosis section).
SECTION B - HISTORY OF PRESENT ILLNESS (HPI)
Written: "Pt came in hospital c above mentioned complained for further Rx and management"
Explanation: The patient came to the hospital with the above-mentioned complaints seeking further Rx (treatment/prescription) and management. This suggests she may have been previously evaluated elsewhere or this is a follow-up admission for definitive treatment (surgery) of her known condition.
SECTION C - PAST MEDICAL HISTORY
Written: NAD
Explanation: NAD = No Abnormality Detected (or "No Active Disease"). The patient has no significant past medical conditions - no diabetes, hypertension, thyroid disease, heart disease, asthma, or other chronic illnesses on record. This is clinically important because it means she is likely a low-risk surgical candidate.
SECTION D - PAST SURGICAL HISTORY
Format: Year / Procedure / Hospital / Anaesthesia
Written: NAD
Explanation: No previous surgeries. She has never had an operation before. This means she has no prior anaesthesia reactions, no surgical complications history, and no previous abdominal/pelvic scars that could complicate the current surgery.
SECTION E - PATIENT FAMILY HISTORY
Written: Not Significant
Explanation: No relevant family history of hereditary conditions - no family history of cancers, bleeding disorders, diabetes, hypertension, or gynaecological malignancies. This is reassuring for the working diagnosis of a benign uterine fibroid.
SECTION F - PSYCHOSOCIAL HISTORY (Page 2, Left Side)
Fields: Smoke / Tobacco / Alcohol / Drug (each marked None/Yes)
Written: All marked None (no substance use)
Explanation: The patient does not smoke, use tobacco, consume alcohol, or take recreational drugs. This is medically important as these substances affect anaesthesia, wound healing, and surgical risk.
SECTION G - PERSONAL HISTORY
Marital Status: Married
Occupation: (appears blank)
Personal History written: "Medeant progestpone pelly and" - this appears to read Medroxyprogesterone (a hormonal medication) was being taken. This is a progestogen commonly used to manage uterine fibroids and abnormal uterine bleeding.
CURRENT MEDICATIONS
Written: NAD (No Active/current medications formally listed beyond the personal history note)
ALLERGIES
Written: Not Significant
Explanation: No known drug or food allergies. This is critical pre-operatively - it means she can receive standard anaesthetic agents, antibiotics, and pain medications without allergy precautions.
GENERAL & PHYSICAL EXAMINATION (Right side of Page 2)
Consciousness Level
Written: Conscious - checked, Stable
- Patient is fully awake and oriented. Not drowsy, not unresponsive.
VITAL DATA TABLE
| Parameter | Value | Normal Range | Interpretation |
|---|---|---|---|
| B.P. | 132/86 mmHg | <120/80 normal | Mildly elevated (Stage 1 hypertension range) - could be pain/anxiety related |
| Pulse | 73/min | 60-100/min | Normal heart rate |
| Resp rate | 18/min | 12-20/min | Normal breathing rate |
| Temp | 97.8°F | 97-99°F | Normal temperature - no fever |
| SpO2 | 97% | >95% normal | Good oxygen saturation - lungs functioning well |
| Pain Score | (not clearly documented) | 0-10 scale | Numeric rating of pain severity |
Clinical Signs Assessment
| Sign | Finding | Meaning |
|---|---|---|
| Pallor | Checked (✓) | Paleness present - suggests mild to moderate anaemia, consistent with chronic uterine bleeding from fibroids |
| Icterus | Checked | Slight jaundice/yellowness - requires attention; could be mild or a tick indicating it was assessed |
| Cyanosis | Checked | Blue discolouration - was assessed; SpO2 97% argues against significant cyanosis |
| Raised JVP | Checked | Jugular Venous Pressure - assessed for cardiac/fluid overload |
| Lymphadenopathy | Checked | Lymph node examination - done |
| Pedal Edema | Checked | Ankle swelling - assessed |
Review of Systems
| System | Finding |
|---|---|
| Respiratory/Cardiovascular | Chest B/L AE (Bilateral Air Entry) - both lungs have equal breath sounds, normal |
| Gastro Intestinal | P/A Soft - Per Abdomen Soft - abdomen is soft on palpation (no rigidity/guarding) |
| Genito Urinary | NAD |
| Hematologic/Lymphatic | NAD |
| Other Specific | NDA (No Data Available) |
| Previous investigation/Medication | NDA |
PROVISIONAL DIAGNOSIS (Page 3)
Written: "Uterine Fibroid"
Explanation: A uterine fibroid (also called leiomyoma) is a benign (non-cancerous) growth of the muscular wall of the uterus. It is the most common gynaecological tumour in women of reproductive age. In a 40-year-old woman presenting with abdominal pain and per vaginal bleeding, fibroid is the classic diagnosis.
Clinical connection: The pallor (anaemia from blood loss), abdominal pain, and per vaginal bleeding are all classic symptoms of uterine fibroids.
INITIAL INVESTIGATIONS ADVISED
- ECG - Checked (Electrocardiogram - pre-operative heart assessment)
- ECHO - Not checked
- TMT - Not checked (Treadmill Test)
- CAG - Not checked (Coronary Angiography)
- X-Ray - Not checked
- Lab Investigations - Pre-operative blood tests (CBC, coagulation, renal function, blood group, etc.)
Rx TREATMENT
Written: "Admit for Surgery - Consent for Surgery"
Explanation: The RMO has recommended admission for surgical management of the fibroid. The patient and/or her family are to be counselled and formal surgical consent is to be obtained. The surgery for fibroids is typically a myomectomy (removal of fibroids) or hysterectomy (removal of uterus), depending on the patient's preference for future fertility.
SPECIAL PRECAUTIONS
Written: "Vital Monitoring"
Explanation: Regular monitoring of blood pressure, pulse, temperature, SpO2, and urine output. Given the mildly elevated BP (132/86), this is particularly important pre-operatively.
DIETARY ADVICE
Written: "Avoid oily spicy food"
Explanation: Light, bland diet recommended pre-operatively. Oily and spicy food can cause nausea, vomiting, and GI upset, which is problematic when the patient may be heading for surgery (also important as she may need to be kept nil by mouth - NBM - before the operation).
DOCTOR SIGNATURE
The RMO's signature is present at the bottom right - confirming the assessment was completed and documented by the responsible physician.
SUMMARY
Mrs. Rekha, a 40-year-old married woman, was admitted to Holy Heart Hospital's Gynaecology unit on June 11, 2026, under Dr. Shashi Chauhan. She presented with abdominal pain and per vaginal bleeding as a known case of uterine fibroid. She has no past medical or surgical history, no allergies, and is a non-smoker/non-drinker. On examination she was conscious, stable, with mildly raised BP and pallor (suggesting anaemia from chronic blood loss). She was admitted for surgical management with pre-op ECG and lab investigations ordered, vital monitoring, and dietary restrictions advised.
Its BPV in cheif complaint not RPV
Thank you for the correction! Here is the updated explanation for that part of the Chief Complaints:
SECTION A - Chief Complaints (Corrected)
Written:
P/L - Both NVD, Pain Abdomen, BPV, c/k/oBPV = Bleeding Per Vaginum
This means vaginal bleeding - the patient is experiencing bleeding from the vagina. This is one of the most classic and prominent symptoms of uterine fibroids.
Why BPV happens in Uterine Fibroid:
- Fibroids distort the uterine cavity and increase the surface area of the endometrium (inner lining)
- This leads to heavy, prolonged, or irregular menstrual bleeding
- Over time, chronic BPV causes iron deficiency anaemia - which explains the pallor found on examination
- In a 40-year-old woman, BPV with a known fibroid is a strong indication for surgical intervention
Clinical connection in this patient:
- BPV (bleeding) → chronic blood loss → Pallor/Anaemia (found on examination)
- BPV + Pain Abdomen + known fibroid = clear indication for the surgical management planned
So the complete Chief Complaints picture is:
| Complaint | Meaning |
|---|---|
| P/L - Both NVD | Labour/delivery history or per local bilateral findings |
| Pain Abdomen | Abdominal pain from fibroid bulk/pressure |
| BPV | Bleeding Per Vaginum - vaginal bleeding from the fibroid |
| c/k/o | Confirmed known case of uterine fibroid |
Apologies for the earlier misread - BPV is actually the more clinically consistent and expected finding here given the diagnosis of uterine fibroid.
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