Medical e log book

CC -20 year old male came to casuality with c/o Giddiness since 1week, SOB on exertion since 2days with nausea and vomiting HOPI- patient was apparently asymptomatic 1week ago then he doveloped giddiness which was sudden in onset no aggravating factors relieved on consumption of food. Later he doveloped SOB 2 days ago with no aggravating and reliving factors along with nausea and vomiting with consumption of food as aggravating factor. PAST HISTORY- K/C/O cushings syndrome PERSONAL HISTORY- occupation -student Mixed diet appetite -normal  bowel and bladder - Normal no addiction  FAMILY HISTORY - not significant  PHYSICAL EXAMINATION- no pallor, icterus, cyanosis, clubbing, dehydration  VITALS- temperature - afebrile  pulse rate - 80 bpm  RR - 12 cpm  BP - 80/50 mm hg  SPO2 - 98 on RA  GRBS - 117.mg % SYSTEMIC EXAMINATION- CVS-S1 ,S2 heard ,no murmurs  RS -BAE +  P/A - soft ,non tender  CNS - speech - normal   power  U.L - 5/5  L.L - 3/5 at presentation in opd ,now 4/5  TONE - normal 

40 yr old female came with complaints of fever since 20 days and SOB since 3 days GRADE 2 TO 4, vomitings since 1 day, decreased urine output since 1 day Patient was apparently alright 20 days back then she had insidious onset of intermittent fever,low grade, with evening raise of temperatureassociated with chills and rigors, relieved on taking medication. From 3 days patient is having sob while washing clothes, cleaning utensils, which was gradually progressive not associated with any orthopnea or pnd or any pedal edema From 1 day patient had sob grade 4 even on rest had 2 episodes of vomitings non projectile non bilious contains food particles non foul smelling.from 1 day patient is having decreased urine output with sob patient was taken to local hospital, conservative treatment done,and refer to our hospital Past history: n/k/c/o DM/TB/ASTHMA/epilepsy K/C/O HTN since 3 years not on any medication Personal history:consumes alcohol daily since 5 years General examination: No picckle