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...

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 ...

 45 year old female patient came to casuality with c/o B/L left leg swelling since 1 and half year and right toe swelling and relieved treatment. Since 1 month she developed B/L upper limb and face along with abdominal distention with decreased urine output since 10 days. She started to experience dyspnea on exertion since 20 days which aggravated to dyspnea at rest since 3 days increased onlying down in supine position. Also C/o non productive cough since 5 days. Treatment history: 1. T. DYTOR 10 MG BD  2. T. MET XL 12.5 MG OD 3. T ATORVAS 40 MG OD 4. SYP ARISTOZYME 10 ML TID 5. T FRUSELAC 50 MG OD DAILY WITH T. METXL 3D 50 MG OD Patient is diagnosed with DM 2 since 2 years and is on T. Glimi M2 BD  Personal history: Passed stools 2 days back with reduced urine output. General Examination: Patient was C/C/C No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema Vitals at admission: PR- 80 bpm BP- 170/60 mmHg RR- 22 cpm SpO2- 98%  CVS: S1 S2 +,...

Patient brought to casualty with complaints of unresponsiveness since 4 am morning Yellowish discoloration of sclera and eyes since 6 months Abdominal distension since 1 week Pedal edema since 1 week HOPI : patient was apparently normal till 6 yrs (2014) back then he developed jaundice with altered behaviour went to local hospital and diagnosed with CLD Patient was chronic alcoholic since 20yrs In 2014 patient visited hospital with c/o b/l pedal edema, jaundice and abdominal distension and was diagnosed with CLD Since then patient was on irregular medication and continued taking alcohol intermittently Since 4 days, patient has c/o fever subsided now used 4 tablets of DOLO C/o loose stools 4-5 episodes per day,no h/o malena , pain abdomen C/o nausea and loss of appetite C/o altered sensorium since today morning not responding to commands No h/o weakness and no h/o involuntary movements PAST HISTORY:      N/K/C/O HTN/DM/ASTHMA/CAD       K/C/O PULMONARY KOCHS ...