Anahita behara

 Admission Date: 07/03/2024 01:00 PM Discharge Date Date:21/04/2024 Discharge Type: Relieved Diagnosis CKD ON MHD Case History and Clinical Findings C/O PEDAL EDEMA SINCE 1 WEEK C/O DECREASED URINE OUTPUT SINCE 1 WEEK PT WAS APPARENTLY ASYMPTOMATIC 1 WEEK AGO THEN HE DEVELOPED PEDALEDEMA SINCE 1WEEK , WHICH WAS INSIDIOUS IN ONSET AND GRADUALLY PROGRESIVE IN NATURE ALSO C/O DECREASED URINE OUTPUT SINCE 1 WEEK N/K/C/O HTN , CVA , CAD , ASTHMA O/E: NO PALLOR ICTERUS CYANOSIS CLUBBING AND GENERALIZED LYMPHADENOPATHY PEDAL EDEMA PRESENT TEMPERATURE 97.8 PR- 79BPM RR-18CPM BP- 140/90 GRBS 112 SPO2- 98% AT RA CVS- SI S2HEARD NO THRILLS AND MURMURS RS- B/LAE NVBS HEARD P/A- SOFT AND NON TENDER NO PALPABLE MASS CNS - NFND CRANIAL NERVES INTACT SENSORY AND MOTOR SYSTEM NORMAL Investigation LIVER FUNCTION TEST (LFT) 06-03-2024 12:55:PM Total Bilurubin0.77 mg/dlDirect Bilurubin0.20 mg/dlSGOT(AST)10 IU/LSGPT(ALT)10 IU/LALKALINE PHOSPHATASE473 IU/LTOTAL PROTEINS7.4 gm/dlALBUMIN3.68 gm/dlA/G RATIO0.9

  CASE :   DIAGNOSIS :  diagnosis  RTA , TRAUMATIC BRAIN INJURY(20/3/23) WITH INTRAVENTRICULAR HEMORRHAGE(RESOLVED) WITH ASPIRATION PNEUMONIA(RESOLVED) FRONTAL BONE FRACTURE s/p -RIGHT FRONTAL LACERATION SOFT TISSUE REPAIR WITH DEBRIDEMENT WAS DONE ON 21/3/23.HFMEF (EF-50%)  SUDDEN CARDIAC ARREST-? HIE ON MECHANICAL VENTILATION DAY-5 (25/3/23) POST CPR STATUS(2CYCLES) ON (25/3/23 ) ANTERIOR WALL MI (EVOLVED)  S/P TRACHEOSTOMY (29/3/23) RECURRENT HYPOKALEMIA WITH GRADE 2 BED SORE (DAY2) ?SEPSIS with LEFT MIDDLE LOBE CONSOLIDATION ? ventilator associated pneumonia  COURSE IN HOSPITAL  25 YEAR OLD MALE PATIENT BROUGHT TO CASUALTY WITH H/O FALL FROM BIKE UNDER ALCOHOL INFLUENCE AT 9:30 PM NEAR HALIYA,NALGONDA ON 20/03/23. AND THEN TAKEN TO HOSPITAL FOR FURTHER MANAGEMENT.PATIENT IS INVESTIGATED AND DIAGNOSED TO HAVE RTA , TRAUMATIC BRAIN INJURY,WITH INTRAVENTRICULAR HEMORRHAGE WITH FRONTAL BONE FRACTURE WITH ASPIRATION PNEUMONIA AND RIGHT FRONTAL LACERATION SOFT TISSUE REPAIR WITH DEBRIDEM

date of admission 3/5/2024  date of discharge 16/5/2024   Diagnosis RADIATION ENTERITIS WITH RIGHT HYDROURETERO NEPHROSIS KNOWN CASE OF CARCINOMA CERVIX POSTHYSTERECTOMY STATUS Case History and Clinical Findings C/O PAIN ABDOMEN SINCE 10 DAYS LOOSE STOOLS SINCE 6 DAYS HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK, THEN HE DEVELOPED PAIN PAIN ABDOMEN DIFFUSE INSIDUOUS ONSET GRADUALLY PROGRESSIVE AND SUBSIDED YESTERDAY EVENING .SQUEEZING IN NATURE AGGRAVATED ON TAKING FOOD AND RELIEVED ON PASSING TOOLS H/OLOOSE STOOLS SINCE 6 DAYS FOOD AS CONTENT10-12 EPISODES PER DAY H/O FEVER LOW GRADE INTERMITTENT DURING NIGHT RELIEVED ON TAKINGMEDICATION NOT ASSOCIATED WITH CHILLS AND RIGOR NO H/O VOMITING . PAST HISTORY: K/C/O HYPOTHYROIDISM AND ON CARBIMAZOLE 2.5 MG OD NO H/O SIMILAR COMPLAINTS IN THE PAST. N/K/C/O DM, HTN, TB , CKD ,CVA , ASTHMA,EPILEPSY ,THYROID. H/O OF CARCINOMA CERVIX 1 YEAR AGO FOR WHICH HYSTERECTOMY WAS DONE F/B RADIOTHERATY AND CHEMOTHERAPY FOR 3 MONTHS PATIENT IS CO

 Diagnosis DENGUE PYREXIA (NS POSITIVE) CHRONIC KIDNEY DISEASE ON MAINTENANCE HEMODIALYSIS Case History and Clinical Findings PATIENT CAME WITH C/O FEVER SINCE 3DAYS, CHEST PAIN SINCE TODAY MORNING HOPI- PT WAS APPARENTLY ASYMPTOMATIC TILL TODY MORNING THEN SHE DVELOPED CHEST PAIN WHICH IS SUDDEN IN ONSET, GRADUALLY PROGRESSIVE(BURNING TYPE, LOCALISED, LEFT SIDED) ASSOCIATED WITH SOB GRADE III C/O PEDAL EDEMA, BILATERAL PITTING TYPE, GRADE II H/O FEVER 3 DAYS AGO WITH GENERALISED BODY PAINS TESTED NS POSITIVE 3 DAYS AGO WITH YESTERDAY PLATELETS 65OOO NO C/O BURNING MICTURITION, VOMITINGS, LOOSE STOOLS, BLEEDING GUMS, HEMATEMESIS, HEMOPTYSIS, PURPURA, RASHES, PALPITATIONS. PAST HISTORY- H/O LEFT PCNL + DJ STENTING DONE 3 MONTHS AGO WITH STENT REMOVAL DONE LEFT MULTIPLE CALCULI , B/L HUN WAS PRESENT L>R K/C/O CKD SINCE 3 MONTHS ON DIALYSIS SINCE 20 DAYS ,8 HD DONE. NOT A K/C/O DM, HTN, CAD,CVA, ASTHMA, THYROID DISORDERS. FAMILY HISTORY- INSIGNIFICANT MENTRUAL HISTORY- MENOPAUSE ATTAIN

 Diagnosis date of admission 27/1/2024  date of discharge 29/1/2024 DENGUE FEVER, WITH THROMBOCYTOPENIA, NS1 POSITIVE DENOVO TYPE 2 DM Case History and Clinical Findings PATIENT CAME WITH C/O FEVER SINCE 10 DAYS, COUGH, COLD WITH 10 DAYS, LOOSE WATERY STOOLS 10 DAYS BACK PATIETN WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO , THEN DEVELOPED FEVER LOW GRADE, ASSOCIATED WITH CHILLS AND RIGORS, PERIODIC, ASSOCIATED WITH COUGH, COLD 10 DAYS BACK, DRY COUGH AND RESOLVED 5 DAYS BACK. LOOSE STOOLS , NON BLOOD STAINED, 3-4 EPISODES 10 DAYS BACK, RESOLVED 5 DAYS BACK NO H/O VOMITING, BURNING MICTURITION PAST HISTORY NO H/O HTN, DM, TB, ASTHMA, EPILEPSY NO ADDICTIONS PERSONAL HISTORY: DIET:MIXED SLEEP:ADEQUATE BOWEL AND BLADDER:REGULAR ADDICTIONS:NO APPETITE:NORMAL GENERAL EXAMINATION: PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON. NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA. VITALS: TEMPERATURE:98.6 BP:120/80 MM HG PR:84 BPM RR:18 CPM SYSTEMIC EXAMINATI

 Diagnosis DENGUE FEVER WITH THROMBOCYTOPENIA TYPE -2 DIABETES MELLITUS SINCE 2 YEARS Case History and Clinical Findings C/O FEVER SINCE 3 DAYS HEAD ACHE SINCE 3 DAYS WEAKNESS SINCE 3 DAYS SWELLING OF BOTH LOWER LIMBS SINCE 1 WEEK PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN DEVELOPED FEVER WHICH WAS LOW GRADE PERIODIC,ASSOCIATED WITH CHILLS AND RIGORS HEAD IS SUDDEN IN ONSET,ASSOCIATED WITH FEVER NO H/O COUGH ,COLD,VOMOTINGS,DIARRHEA,BLOOD STAINED STOOLS,VOMITINGS K/C/O DIABETES MELLITUS ON TAB.METFORMIN 500 MG SIONCE 2 YEARS NO H/O HYPERTENSION,TB,ASTHMA,EPILEPSY CHRONMIC SMOKER 2-3 (CHUTTA) PER DAY SINCE 20 YEARS NO H/O SIMILAR COMPLAINTS IN THE PAST GENERAL EXAMINATION :- PATIENT WAS CONSCIOUS COHERENT AND COOPERATIVE NO PALLOR ICTERUS CYANOSIS CLUBBING LYPHADENOPATHY AND EDEMA VITALS :- TEMP- AFEBRILE PULSE RATE- 82 BPM RR- 16 CPM BP- 110 / 70 MMHG GRBS- 98 MG/DL SYSTEMIC EXAMINATION :- CVS- S1 S2 HEARED, NO MURMURS RS - BAE + , NVBS CNS - NFND P/A - SOFT NON TENDER , BOWEL

 Diagnosis VIRAL PYREXIA WITH THROMBOCYTOPENIA Case History and Clinical Findings 80YR OLD MALE CAME WITH CHIEF COMPLAINTS OF FEVER SINCE 5 DAYS AND GENERALISED WEAKNESS SINCE 5 DAYS HISTOR OF PREENTING ILLNESS : PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS BACK , THEN HE DEVELOPED HIGH GRADE FEVER WITH DIURNAL VARIATION ASSOCIATED WITH HEADACHE AND NOT ASSOCIATED WITH CHILLS AND RIGORS NO H/O COLD , COUGH , SOB , ABDOMINAL DISTENSION NO H/O PAIN ABDOMEN , LOOSE STOOLS , NAUSEA , VOMITINGS NO H/O BURNING MICTURITION PAST HISTORY : K/C/O DM SINCE 1 YR ON TAB GLYCOMET GP1 H/O CHEST PAIN ? CAD 6 YRS BACK N/K/C/O CVA , SEIZURES , THYROID , ASTHMA GENERAL EXAMINATION- THE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE MODERATELY BUILT AND NOURISHED NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLULBBING, EDEMA VITALS: TEMP: 97 F PR: 74 BPM RR: 16 CPM BP: 140/90 MM HG PO2: 96% @ RA GRBS: 320 MG/DL CVS: S1, S2 HEARS, NO MURMURS RS: BAE+, NVBS TRACHEA: CENTRAL NO DYSPNOEA AND WHEEZE NO RHONCHI ABDOMEN: NO

 Diagnosis VIRAL PYREXIA WITH THROMBOCYTOPENIA (RESOLVING) ACUTE GE (RESOLVED) ORAL CANDIDIASIS S/P 2 SDP TRANSFUSIONS ON 6/4/24 , 8/4/24 Case History and Clinical Findings A 35Y/F CAME WITH C/O FEVER SINCE 3DAYS , LOOSE MOTIONS AND VOMITINGS SINCE 3 DAYS PT. WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO , THEN SHE DEVELOPED FEVER , WHICH WAS INSIDIOUS IN ONSET , HIGH GRADE , INTERMITTENT A/W CHILLS RESOLVED ON MEDICATION H/O VOMITINGS 5-6 EPISODES , FOOD ASSOCIATED , NON-PROJECTILE, NON-BILIOUS H/O LOOSE STOOLS -3 EPISODES PER DAY , WATERY IN CONSISTENCY H/O PETECHIAE OVER PALATE , RETRO ORIBITAL PAIN , MELENA , SOB N/H/O PAIN ABDOMEN PAST HISTORY N/K/C/O DM,HTN,ASTHMA,EPILEPSY,THYROID DISORDERS GENERAL EXAMINATION PATIENT IS CONSCIOUS COHERENT CO-OPERATIVE TEMP 98 F PR 88 BPM RR 20 CPM BP 110/70 MMHG SPO2 98 CVS S1 S2 HEARD NO MURMURS RS: DYSPNEA: GRADE II TO III NYHA, TRACHEA CENTRAL, VESICULAR BREATH SOUNDS ABDOMEN: SCAPHOID, SOFT, NON TENDER CNS: GCS E4V5M6, CONSCIOUS, NORMAL SPEECH REFL

 Diagnosis VIRAL PYREXIA WITH THROMBOCYTOPENIA ACUTE KIDNEY INJURY ? URINARY TRACT INFECTION Case History and Clinical Findings A 50 YR OLD MALE CAME TO CASUALTY WITH C/O FEVER SINCE 4 DAYS COUGH AND COLD SINCE 4 DAYS C/O BODY PAINS HEADACHE ABDOMINAL PAIN VOMITINGS SINCE 4 DAYS HOPI PATIENT WAS APPARENTLY ASYMPTOMATIC SINCE 4 DAYS AGO THEN HE DEVELOPED FEVER INTERMITTENT LOW GRADE A/W CHILLS AND RIGORS NO DIURNAL VARIATION NO MYALGIA RETROORBITAL PAIN GENERALISED WEAKNESS + H/O VOMITING 1 EPISODE FOOD AS CONTENT NON PROJECTILE NON BILIOUSNON FOUL SMELLING H/O FRONTAL HEADACHE INTERMITTENT H/O ABDOMINAL PAIN AND REBOUND TENDERNESS+ H/O COUGH COLD SPUTUM + SCANTY WHITISH NON BLOOD STAINED NON FOUL SMELLING H/O BODY PAINS PAST HISTORY N/K/C/O HTN, DM, TB, ASTHMA, EPILEPSY, THYROID DISORDERS, CAD CVA PERSONAL HISTORY: OCCUPATION-FARMER DIET-NON VEGETARIAN APPETITE-LOST SLEEP-ADEQUATE BOWEL MOVEMENTS-REGULAR ADDICTIONS- ALCOHOLIC STOPPED 5 YEARS AGO GENERAL EXAMINATION: AFEBRILE 98.2 F BP:

 Diagnosis VIRAL PYREXIA WITH DENGUE IGM POSITIVE (RECOVERED) UTI Case History and Clinical Findings PATIENT CAME WITH CHIEF COMPLAINTS OF - FEVER (HIGH GRADE) SINCE 9 DAYS -BURNING MICTURITION SINCE 9 DAYS -NAUSEA AND VOMITINGS SINCE 9DAYS -HEADACHE(DIFFUSE) WITH NECK PAIN SINCE 9DAYS -BODY PAINS SINCE 9DAYS -DRY COUGH (INTERMITTENT) SINCE9DAYS HISTORY OF PRSENT ILLNESS PATIENT WAS APPARANTELY ASYMPTOMATIC9 DAYS AGO.THEN SHE DEVELOPPED FEVER (HIGH GRADE) ASSOCIATED WITH CHILLS AND RIGORS,INCREASE IN TEMPERATURE AT NIGHT AND RELIEVED ON TAKING MEDICATION AND REVERTS BACK.SHE ALSO DEVELOPPED NAUSEA VOMITING 9 DAYS BACK.SHE ALSO DEVELOPPED HEADACHE(DIFFUSE) ASSOCIATED WITH NECKPAIN SINCE 9 DAYS.SHE HAVE BODY PAINS FROM 9DAYS.SHE HAD DRY COUGH(INTERMITTENT) FROM 9DAYS BRIEF COURSE IN HOSPITAL 24 YEAR OLD FEMALE CAME TO THE CASUALTY ON 19/09/2022 WITH CHIEF COMPLAINTS OF -FEVER (HIGH GRADE) SINCE 9 DAYS.ASSOCIATED WITH CHILLS AND RIGORS.RAISE IN TEMPERATURE SEEN AT NIGHT AND RELIEVED ON ME

 Diagnosis DENGUE WITH THROMBOCYTOPENIA Case History and Clinical Findings pt complaining of fever with chills, generalized body pains and headache since 4 days.HOPI:Pt was apparently asymptomatic 4 days ago then developed fever with chills which was relieved on medication which he took from the local hospital and had undergone investigations for which he was found to be positive for dengueHe also had a low platelet count of 14,000 so was referred to our hospitalH/O Past illnessNot a known case of hypertension, DM,heart disease,tb, epilepsy, thyroid disorder.CVS: S1 , S2+RESP:BAE+P/A: soft , nontenderCNS: NAD Investigations  Name  Value  Range  Name  Value  Range  BLOOD UREA 12- 26 mg/dl 42-12 mg/dl 08-2022 08:07:PM  SERUM 1.0 mg/dl 1.3-0.9 mg/dl CREATININE 12-08- 2022 08:07:PM  SERUM ELECTROLYTES (Na, K, C l) 12-08-2022 08:07:PM 145-136 mmol/L 5.1-3.5 mmol/L 98-107 mmol/L SODIUM POTASSIUM CHLORIDE 140 mmol/L 3.9 mmol/L 102 mmol/L  LIVER FUNCTION TEST (LFT) 12-08-2022 08:07:PM 1-0 mg/d

 Diagnosis VIRAL PYREXIA WITH THROMBOCYTOPENIA Case History and Clinical Findings C/O FEVER SINCE 5 DAYS HOPI- PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS BACK THEN DEVELOPED HIGH GRADE FEVER, ASSOCIATED WITH CHILLS AND RIGORS, NO DIURNAL VARIATION, RELIEVED WITH MEDICATION. C/O LOOSE STOOLS 8-10 EPISODES TODAY AND AROUND 4 EPISODES YESTERDAY, WATERY IN CONSISTENCY, NON-FOULSMELLING, NON BLOOD STAINED. NO C/O RASH/HEMATURIA/BLEEDING MANIFESTATIONS/PETTECHIAE RETRO ORBITAL PAIN+, LOSS OF APPETITE+ NO C/O SOB/PALPITATIONS/ CHEST PAIN/ ORTHOPNEA/ PND PAST HISTORY- NOT A K/C/O HTN,DM,EPILEPSY, THYROID DISORDERS GENERAL EXAMINATION: PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE WELL ORIENTED TO TIME, PLACE, PERSON. MODERATELY BUILT AND NOURISHED. NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS, LYMPHEDENOPATHY, EDEMA TEMPEARTURE: 102 F PULSE RATE: 110 BPM BLOOD PRESSURE: 110/70 MMHG RESPIRATORY RATE: 16 CPM SPO2: 98% @ RA CVS: S1, S2 HEARD, NO MURMURS RS: BAE +, NVBS P/A: SOFT, NON TENDER, NO ORG

 Diagnosis DENGUE WITH THROMBOCYTOPENIA (NS1` POSITIVE) ACUTE KIDNEY INJURY (RESOLVING) DENOVO HYPERTENSION K/C/O HYPOTHYROIDISM SINCE 3 YEARS Case History and Clinical Findings PATIENT CAME TO CASUALITY WITH C/O FEVER SINCE 5 DAYS HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS AGO , THEN SHE DEVELOPED FEVER SINCE 5 DAYS , LOW GRADE , INSISDIOUS IN ONSET , INTERMITTENT TYPE, NOT ASSOCIATED WITH CHILLS AND RIGORS AGGRAVATED DURING NIGHT AND RELIEVED ON MEDICATION . H/O NAUSEA SINCE 1 DAY NO H/O VOMITING , ABDOMINAL PAIN , BURNING MICTURITION , CONSTIPATION NO H/O CHEST PAIN , SOB , PLAPITATIONS , SWEATING NO H/O MYALGIA , ARTHRALGIA PAST HISTORY : K/C/O HYPOTHYROIDISM (TAB . THYROXINE 100 MG PO/OD) N/K/C/O DM , HTN , ASTHMA ,TB , EPILEPSY , CVA . CAD O/E: PT IS C/C/C NO SIGNS OF PALLOR , ICTERUS , CYANOSI, CLUBBING , LYMPHADENOPATHY, EDEMA VITALS - TEMPERATURE : 98.2 DEGREE FARENHEIT BP:120/90 MMHG PR : 76 BPM RR:18 CPM SPO2 :99% GRBS : 146 MG% CVS : S1 S2 HEARD RS : BAE + , NVBS P/A: