Medicine case elog book

Pt. Came to the casuality with c/o vomitings since 2days. C/o giddiness since 2days. C/o chills since 30min. Hopi: Patient was apparently asymptomatic 2days ago. Later developed vomitings since 2days. Food as content with 4 to 5 episodes yesterday and 1episode today. Associated with giddiness since 2days. C/o chills since 30min today after vomiting with headache. C/o thirst present. No c/o fever, loose stools, sob, burning micturition . Not a k/c/o DM, HTN, CAD. Provisional diagnosis: Acute Gastritis with dehydration.  Rx: 1. Inj. PAN 40mg iv od. 2. Inj. Zofer 4mg iv tid. 3. Ivf NS and DNS @ 100ml /hr. 4. T. Dolo 650mg po tid  5. Ors sachets in 1lt water bd. Day 2: 1. Tab. PAN 40mg iv od. 2. Tab. Zofer 4mg iv tid. 3. Ivf NS and DNS @ 100ml /hr. 4. T. Dolo 650mg po tid  5. Ors sachets in 1lt water bd. 6. Tab. Mefthal spas bd.

A 78yr old female came with the c/o itching all over the body since 5 to 6 months. HOPI:  Patient was apparently asymptomatic 6 months back. Later developed pruritis all over the body. Insidious in onset and gradually progressed to all over the the body. Then she used ayurvedic body lotion for the pruritus, which was not subsided. There is darkening and roughness of skin. Associated with decreased appetite and weight loss. Later on suggestion of a doctor for the yellowish discoloration of the conjunctiva, investigations were done showing tb levels of 5. Later even usg was peformed showing distention of gallbladder with thickening of wall and calculi in the gallbladder. K/C/O HTN since 30yrs and on regular medication and controlled BP. N/k/c/o DM, Epilepsy, asthma, tb. O/e: Pt is c/c/c.  Bp: 130/70mmhg Pr:64bpm Rs: bae+ Cvs: s1s2+ Cns: NAD. P/A : Soft and non tender. Bs: + Ecg: USG: Chest x ray: Investigations: Surgery referal: