internal assessment 2
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45 years old male with seizures one week back
CHIEF COMPLAINTS an episode of seizures 1 week back and he had bleeding from mouth HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 20 years ago after which he started consuming alcohol ,initially he started consuming toddy when he was young then he started consuming alcohol with his friends at his work 3-6 units weekly once on Sunday.This continued for 7years back.He started consuming alcohol excess due to family problems.he had 3 years back ah/o of 3episodes of seizures each episode precedes consumption of alcohol is present.he decided that alcohol might be the reason and went to a local doctor who told the same reason for which he decided to stop consuming alcohol which he did.he was abstinent for one year.Again he started consuming alcohol duo to family problems. One week back then he developed an episode seizures while he was doing his work on monday .Then he went to the RMP for the treatment he had given ...
A 70 years old female referred from surgery to GM with the shortness of breath and b/l pedal edema
Patient was apparently asymptomatic 2weeks back then she developed right leg swelling associated with wound on the right ankle and right leg anterior region. Swelling extended from the right foot to the mid part of shin.debridement of infection was done four days back.she had h/o of atrial fibrillation before surgery which is controlled. After surgery due to stress induced factor atrial fibrillation which-eventually lead to left heart failure and then right heart failure she developed shortness of breath and pedal edema. No h/o of fever, vomiting Past history: Not known Case of HTN,DM, asthma, qq1 Personal h/o Diet: mixed Bowel and bladder! Regular. Family ho:- No significant family history. GENERAL EXAMINATION: pt is cc and non cooperative, moderately built and moderately nourished, well oriented with place and time, No pallor, no icterus, no cyanosis, no clubbing, no lymphadenopathy. Vitals: Pulse rate- 123 Bp - 110/80 Rr- 22 Temp- 98.4F Oxygen saturatio...
A 60 year old female came to GM OPD with Chief Complaints of fever since ③ days and cough associated with sputum since ③ days.Difficulty in swallowing and pain during swallowing since ③ days, hoarseness of voice since ③ days shortness of breath since ③ days
A 60 year old female came to GM OPD with Chief Complaints of fever since ③ days and cough associated with sputum since ③ days. Difficulty in swallowing and pain during swallowing since ③ dogs, hoarseness of voice since ③ days shortness of breath since ③ days HOPI : The patient was apparently asymptomatic ③ days back then she developed high grade fever, cough with sputum which is whitish in coour non foul smelling and non blood stained. There was a history of difificult in swallowing & pain during swallowing there h/o shortness of breath ③ days back grade -II. decreased appetite since 5-6 months, loss of weight since 1 year.( 20kg wt loss) PAST HISTORY : History of giddiness and fall ,followed by unconsciousness. Known case of hypertension since 1 year but since 5-6 months not on regular medication . Known case of thyroid disorder since 1 year on medication. known case of DM || since ⑨ years and medication since then, tab- glibeclamide in morning, citagl...
50 Year old male came to Casuality with Chief complaints of Fever and Chills Since 1 week and Associated with Frontal Headache. No History of Vomiting,Headache,Loose Stools or Abdominal Pain
Past History Not A K/C/O DM,HTN,Asthma,Epilepsy. No Allergies No Past Surgical History Personal History Diet -Mixed Appeteite- Decreased Bowel And Bladder Movements Regular Addictions Absent Family History No Significant Family History. Provisional Diagnosis : Viral Pyrexia Vitals Bp 100/60 mmHg Pulse 75BPM RR 14cpm GRBS 437 mg/dl Pt Is C/C/C well oriented with Time,Place and Person Pallor Absent Icterus Absent Clubbing Absent Koilonychia Absent Lymphadenopathy Absent Edema Absent Systemic Examination CVS S1 S2 Heard RS BAE Present P/A Soft ,Non Tender. Provisional Diagnosis Viral Pyrexia Investigation Chest X Ray : 30-10-22 28-10-22 Rapid Dengue - NS1 Positive 30/10/22 Urine Sugars - Present Albumin Nil 30-10-22 Platelet Count - 27000 Treatment Tab PCM Inj Neomol Inj Zofer 4mg IV SOS Inj Piptaz 4mg IV BD Tab Doxy 100mg PO BD SOAP NOTES DAY 1 Viral Pyrexia Secondary to Dengue Thrombocytopenia Vitals Bp 120/80 PR 75 GRBS 228mg/d...
A 55yr old female complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days
CHIEF COMPLAINTS: Pt complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days . HOPI: Patient was apparently asymptomatic 3 months back. Then she had multiple swellings in front of the left ear, for which she developed fever which was lowgrade, intermittent, no evening rise of temp, ass with decreased appetite since 1 month. She then had vomitings which was non bilious and non projectile, containing food particles. She had history of loose stools since 3 days, which is 4-5 episodes per day, watery in consistency. Past history: K/c/o Hypertension since 7 years. 7 yrs back she had c/o giddiness for which she went to hospital and was found to have HTN. Personal history: Diet- mixed Appetite-decreased Bowel and Bladder movements- regular. Addictions- Allergies- none General examination : Patient is conscious, coherent and cooperative. Well oriented to time, place and person. Moderately built and mo...