Notes

PATIENT SOHAN LAL, 59 YEAR OLD MALE, RESIDENT OF SAHARANPUR, PRESENTED TO OPD WITH CHIEF COMPLAINT OF GENERALIZED FATIGUE SINCE 4-5 DAYS, EXCESSIVE SLEEPINESS SINCE 2-3 DAYS, SHORTNESS OF BREATH SINCE 7-8 DAYS. THE PATIENT WAS APPARENTLY ALRIGHT 4-5 DAYS BACK WHEN THE PATIENT STARTED HAVING COMPLAINTS OF GENERALIZED WEAKNESS TO SUCH AN EXTENT THAT EARLIER PATIENT USED TO GO TO HIS SHOP, NOW HE CAN WALK ONLY WITH SUPPORT OF HIS FAMILY MEMBERS. PATIENT ALSO HAS SHORTNESS OF BREATH SINCE 3-4 DAYS, NOT ASSOCIATED WITH ORTHOPNEA OR PND, KNOWN CASE OF HYPERTENSION SINCE 2-3 WEEKS, NO HISTORY OF DIABETES MELLITUS, CAD, TB, CVA, THYROID. PAST HISTORY: HISTORY OF BHACO, RIGHT EYE ON 11-04-2025, AT KHANNA, NETHRAL CHAKRASALE. PATIENT HAD PRIOR BP READINGS OF 160-170 POST OPERATION, ON NO MEDICATION WAS ADVISED. PATIENT AFTER 5-6 DAYS HAD THE EPISODE OF SEVERE HEADACHE AND DIZZINESS. PATIENT WAS ADMITTED AT KIRAN HEALTH CARE ON 21-04-2025. ROUTINE INVESTIGATIONS WERE DONE, PATIENT DISCHARGED ON 23-04-2025. ON THE SAME DAY, PATIENT VISITED KIDNEY CLINIC & DIALYSIS CENTER ON 25-04-2025, WHERE PATIENT WAS REFERRED TO A MULTISUPERSPECIALITY HOSPITAL. SURGICAL HISTORY: HISTORY OF UMBILICAL HERNIA SURGERY 10 YEARS BACK. PERSONAL HISTORY: DIET - VEGETARIAN, APPETITE - NORMAL, SLEEP - NORMAL, BOWEL & BLADDER MOVEMENT - INCREASED, ADDICTION - NEGATIVE.