E log book

A 53 year old female patient came to opd with chief complaint of : - shortness of breath since 3days . - decreased urine output.   History of present illness: Patient was apparently asymptomatic 12 years back, she developed high grade fever for which she visited Nalgonda govt hospital, they performed investigations and told her that her kindeys were damaged. Her fever resolved with medication and she went home.  Later in her life, 4 years ago she was experiencing chronic bouts of neck pain, giddiness, and headache, for which she visited Nalgonda govt hospital, where she was diagnosed with hypertension. Ever since she has been on anti hypertensive drugs. 10 months back she developed SOB, for which she visited the hospital, investigations there reavealed that her blood pH, blood urea and creatinine were raised. She was diagnosed with renal failure. For which she underwent dialysis  2-3 times every week. She had blood transfusion 2 times during dialysis.  Three days back she developed sho

 80 yrs old Male came to casualty with  C/O loss of consciousness (for half an hour) C/O involuntary bowel and bladder incontinence and slurred speech since 4am today(19/12/21) HOPI Patient was apparently asymptomatic till 4:00am today got up from bed and walked to washroom ,while walking near the door at 4:00am,patient slipped and fell on the ground-sustained injury to back and head. He had loss of consciousness for half an hour and then regained.Conscious spontaneous with no involuntary movements,froth from mouth. H/O involuntary micturition and defecation present  H/O slurred speech present after fall On presentation patient is conscious,confused,slurred speech present. Past history  N/K/C/O HTN,DM,TB,epilepsy,CVA,CAD Personal history  Diet -mixed Appetite-normal Bowel movements-irregular  He is a toddy drinker and smokes chutta  Family history  Not significant  General examination  Pt is conscious  Vitals Temp-Afebrile  Bp-120/60mmHg PR-90bpm Spo2-99% on RA Systemic examination  CV

A 60 yr old male farmer by occupation, resident of narketpally came to the casuality  with chief complaints of dry cough, sob since 3 days and fever since 1 day. Hopi: patient was apparently asymtomatic 3days back then he had dry cough, progressive in nature not associated with any diurnal/ postural variation. sob initially grade -II gradually progressed to grade-IV.  not associated with any PND,orthopnea, pedal edema. from day 1 patient is having fever, low grade, intermittent, not associated with chills and rigors, relieves on taking medication. No h/o any decreased urine output. Past history:  no H/o of diabetes hypertension,asthma,TB, epilepsy Genral examination: pt is c/c/c,  afebrile. BP-140/80,  pr-104,  sats-89(at 15L of o2) Diagnosis: Viral pneumonia with type 1 respiratory failure with AKI Clinical pictures:- Treatment:- 1. O2 inhalation to maintain spO2 >92% 2. IVF NS, RL @75 mL/ hr 3. Inj. ceftriaxone 1gm iv/bd 4. Tab. AZITHROMYCIN 500 mg po/od 5

60 yr old male,tailor by occupation not working since 3 yrs c/o sob since 3 days,pedal edema since 3days,chest pain since 2hrs. HOPI - pt was apparently asymptomatic 30yrs ago diagnosed with dm,htn  7yrs ago c/o b/l pedal edema,decreased urine output diagnosed with heart failure  10/21 -pt came to our hospital with sob,pedal edema was diagnosed and treated as hfpef,crf,grade 2 bph. Since 3days c/o sob,pedal edema,chest pain since 2hrs  No h/o fever,cold,cough  K/c/o DM,HTN   Personal history: Diet -mixed  Appetite-normal Bowel and bladder-regular  Sleep-adequate  Alcoholic from 25yrs and he stopped 5yrs back and occasional smoker GENERAL EXAMINATION: Pallor -present  Pedal edema-present  No cyanosis,icterus,clubbing,lymphadenopathy  Vitals: Bp-130/80mmhg PR-120 Temp-afebrile  Spo2- 98% at room air  SYSTEMIC EXAMINATION: CVS - s1s2 heard  RS - BAE present  P/A - soft,non tender CNS- NAD PROVISIONAL DIAGNOSIS: Chronic renal failure  HFPEF(EF - 52%) K/c/o DM and HTN since 30yrs Grade 2 p

55 year old man was rushed to the emergency room by his family with complaints of generalised jerky movements of upper and lower limbs, lasting for 2 minutes, that occurred 4 hours ago at 4 AM in the night.  Patient was apparently asymptomatic until yesterday night, when he had sudden jerky movements of upper and lower limbs, associated with loss of consciousness and involuntary micturition back. The patient is disoriented to time, place but recognises his family, there is post ictal confusion. The patient feels tired and week. There are no signs of tongue bite or fracture of long bones. Upon further inquiry the patient gives history of consumption of  alcohol (650ml) for 2 days (3 days prior to presentation) continuously, subsequently, 2 days back he  developed abdominal pain which is dragging type, localised to the right upper quadrant and associated with altered sensorium. Review of systems revealed :- C/o chest pain, dragging type, non radiating to left arm. C/o vomiting 3 days bac