Department Condition Chief complaints Present illness Past History

Pateint came with C/o Throat pain x 2 days. Pain is

persistent over the back of teh throat with moderate to
severe intensity.
General Medicine Throat pain / Fever C/o Throat pain and Fever Has difficulty in swallowing solids. No relevant past
C/o fever since yesterday, not associated with chills or rigor. medical or Surgical
(MALE, 30+) Also C/o of cough (non-productive) and running nose. History.
Patient travelled to Delhi a couple of days back.
Patient denies having Ear pain/clogging, Headache or
nausea.

Department Condition Chief complaints Present illness Past History

 Patient was brought to the ER by his parents, states that he
has abdominall pain since yesterday evening.
Patient denies having outside food, Points left lower lower
abdominal region when questioned about location of pain.
Gastroenterology States that the pain is severe sometimes, dull and Patient had
C/o Dull Abdominal pain
(Female/Male 12+ Appendicitis persistent otherwise. Tonsillectomy in
and fever
years) Also C/o ofsevere nausea/3 episodes of vomiting and hasnt 2008
eaten anything since yesterday.
Denies having diarrhea, feels bloated and hasnt passed
stools since yesterday.
CT done today revealed -

Male 40+ Years colon cancer

Department Condition Chief complaints Present illness Past History

 The patient returns for followup management of type 2
diabetes mellitus. She was diagnosed with Type 2 DM 4
months back while taking a routine health check up. Her
management of HbA1C was 7.2. Patient was on Oral Hypoglycemic agents Systemic
Endocrinology Type 2 DM (Follow Followup for 3 months has now returned with blood work up. Her Hypertension- On
(40+ year old diabetes - Medication
up) HbA1c currently is 6.5 (Responding to OHA) FBS - 137, Amlong 5mg BD
female) Refill. PPBS - 194. Patient was also Hypothryroid, has palced on
Thyronorm 100 mcg, Currently her Her thyroid levels TSH
at present is 5.4 earlier was 7.2 responding well to
medication.

Department Condition Chief complaints Present illness Past History

Patient was on a
Patient came with complains of nausea with vomiting for course of ibuprofen
(bd) last week for 5
the past 3 days, not subsided. days as she was
Last menstrual period was on 24-06-2019.
complains severe epigastric pain immediately after self medicationache
having muscle -
Nausea with vomiting x 3 Patient with
eating.
Gynaecology Pregnancy days no prescription.
Also complains of frequent burping accompanied with
(28 years) (I Trimester) Breast tenderness (+) G2P1L1A1
early satiety and increased appetite.
Dizziness (+) G1 - spontaneous
No complains of diarrhea or constipation. abortion - d&c at 14
States that she has leukorrhea and also complains of weeks
occasional abdominal cramps (RLQ and LLQ) G2- c section -
placenta previa
Department Condition Chief complaints Present illness Past History
 Doc
Family History Personal History Examination Allergies Diagnosis Procedure recommendation

Advised to gargle
Upon examination -The throat thrice a day using
apprears irritated and Salt water or
Patient is a inflammed. betadiene garlgle.
Throat swab
smoker Upon palpation - Tenderness+ Advised to drink
Paternal: Cerical Lymphadenopathy noted. Patient is allergic Pharyngitis - done and sent
Hypertension Approximately warm fluids (not too
to Pennicillin. Unspecified. for
7-8 cigarettes Upon Auscultation - Bilateral air hot/not too cold).
Examintation
per day entry positive, No wheezes. Fruiyts rich in
S1 S2 Heard, No Gallops or Vitamin C such as
murmur. Oranges, Lemons
can be consumed.

Doc
Family History Personal History Examination Allergies Diagnosis Procedure recommendation

No relevant Nonvegetarian
family History
Family History Personal History Examination
The patient is moderately obese
but he is otherwise well Emergency
developed & well nourished. He Appendectomy has
appears in moderate discomfort been planned
but there is no evidence of Patient to be on
distress. He is alert, and oriented NPO (Enanble NPO
to person place and on Diet).
circumstance. Admission request
RESPIRATORY: Normal Vesicular Surgical to be raised
breath sounds
CARDIOVASCULAR - S1S2 Heard, Patient is allergic Acute Management - OT to be booked for
to Peanuts Plan for EMERGENCY
NO murmurs or Gallops. Apendicitis Laparoscopic Surgery
GASTRO_INTESTINAL: Generally Appendectomy Adavance amount
soft. Abdomen is focally tender in to be collected
the right lower quadrant to deep Pre-surgery lab
palpation with no rebound orders to be carried
tenderness. Moderate out
tenderness over the peri- Pre surgery
umbilical area noted. Bowel Medications to be
sounds ++ administered.
McBurney Sign Positive, Psoas
Sign Positive.
Doc
Allergies Diagnosis Procedure recommendation
 Advised to consult
the dietician for a
low glycemic index
Type 2
Mother- No history of any diet
Diabetes
Deceased smoking, Alert, oriented. To do brisk walking
Allergic to dust Mellitus
(Stroke + alcohol, or drug for 20 mins
Hypothyroidis
Breast cancer) abuse. everyday
m Avoid fatty food and
minimize foods rich
in carbohydrates.

Doc
Family History Personal History Examination Allergies Diagnosis Procedure recommendation

Tongue - appears reddish, supple

- no discolorations note Counselled on the
Mouth - no thrush/ulcers need to plan a
Non vegetarian - Thorax - heart sounds normal pregnancy in
s1s2 heard/ no gallops or
often advance.
murmurs heard.
non smoker A Case of Advised to continue
non alcoholic. Lungs clear on auscultation, b/l NIL Confirmed NIL the pregnancy and
Married with 1 Abdomenwith
ae+, nvbs no wheezes Pregnancy to start on Healthy
- tender over the
kid. diet
epigastrium on palpation Alomg with Iron and
Bowel sounds heard + Folic acid
Bimanual palpation - Cervix firm, supplement.
leukorrhea and uterus appears
normal
 Doc
Family History Personal History Examination Allergies Diagnosis Procedure recommendation
Orders Lab Results Radiology Results Plan

1. CBC
2. Rapid Strep Test
3. Peripheral
Smear
4. Monospot test Medical
1. Rapid management
1. T. Azithral Strep test Review after 3
500mg BD 2. Monospot Chest Xray - If symptoms are persistent to be done. days
2. T. Pan 40 mg test SOS if symptoms
OD BF Persistent.
3. T. P650mg OD
(Paracetamol)
4. T. Limcee
(Chewable) OD

Orders Lab Results Radiology Results Plan

1. CBC
2. Viral Serology CLINICAL HISTORY: ABDOMINAL PAIN. TECHNIQUE: Multiple axial CT
3. Bleeding time / 1. CBC images were obtained through the abdomen and pelvis after
Clotting time RESULT with administration of oral contrast material only. COMMENTS: There is
4. Blood grouping ELEVATED no evidence of diffuse hepatic hypoattenuation. There is no intra or
Typing WBC extrahepatic biliary ductal dilatation. The spleen is normal. The
pancreas is of normal contour and attenuation characteristics. There Surgical
1. Inj. Taxim IG IV White blood is no evidence of adrenal mass. No evidence of hernia is noted. The Managemnt -
STAT in 100Ml NS cell count is kidneys are normal in size, shape and configuration. No renal or Emergency
2. Inj. TT 1/2 cc IV 12000, ureteral calculi are identified. There is no hydroureter or Appendectomy
STAT hemoglobin hydronephrosis. There is severe inflammation of the appendix
3. Inj. Xylocaine 13.6, and measuring about 12mm in diameter with a outer wall thickening of
Test dose platelet count 3mm, periappendiceal fat appears hyperemic and mesenteric lymph
4. Inf. Para 500mg - 4lakhs nodes enlarged suggestive of appendicitis. Several fluid-filled loops
SOS of small bowel are present compatible with mild enteritis. There is
no bowel wall thickening. No evidence for small or large bowel
obstruction. There is no evidence of abdominal ascites. There is no
evidence of intrinsic or extrinsic bladder mass. There is no pelvic
ascites or lymphadenopathy.
IMPRESSION : There is severe inflammation of the appendix
measuring about 12mm in diameter with a outer wall thickening of
3mm, periappendiceal fat appears hyperemic and mesenteric lymph
nodes enlarged suggestive of appendicitis.
Suggested too co-relate Clinically.

Orders Lab Results Radiology Results Plan

FUTURE ORDERS
1. Blood sugar
2. LFT, RFT
3. HbA1C
4. TSH/T3/T4
5. Lipid Profile Cholesterol-
223,
1. T. Rosuvas triglyceride Nil Medical
10mg OD 140, HDL 54, management
2. T. Thyronorm and LDL 144.
100 mcg OD BF HbA1C- 6.5
3. T. Glimipride
GP2 1-0-1
4. T. Pioz 7.5mg 0-
1-0

Orders Lab Results Radiology Results Plan

UTP - Positive
1. Beta HCG An hCG level Fetal heart action present Frequency 156 bpm
2. Urine of less than 5 Crown-rump length (CRL) 55.1 mm
Pregnancy Test
3. (If 1&2 Positive) mIU/mL is Biparietal diameter (BPD) 19.4 mm
considered Nuchal translucency (NT) 1.40 mm
Transvaginal
Ultrasonography negative for Nasal bone (tick one or leave blank) - ✔
pregnancy, Present
and anything Fetal anatomy: ANC
1. T. Folvite OD
2. C. Dexorange above 25 Skull/brain appears normal, heart not examined, spine appears
mIU/mL is normal, abdomen appears
OD considered normal, stomach visible, bladder visible, hands both visible, feet
3. T. Calcimax OD positive for both visible.
4. T. Emeset 4mg pregnancy. Placenta: Posterior
STAT + SOS Amniotic fluid: Normal
Orders Lab Results Radiology Results Plan