Kingdom of Saudi Arabia ‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬

Ministry of Education ‫وزارة اﻟﺘﻌﻠﯿﻢ‬

‫ﺟﺎﻣﻌﺔ اﻟﺠﻮف‬
AL Jouf University ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬
College of Medicine

Al Jouf UNIVERSITY
FACULTY OF MEDICINE
DEPARTMENT OF INTERNAL MEDICINE
COURSE: MED 411 / MED 412
LOGBOOK
4th Year Medicine
From 29/8/2021 to 6 /1 /2022

Student Name:
Nouf Alumni
Student ID: 381205045
 Patient ( ) Clerking
fahnie
Initial Patient Name :-------------------------------------------------------
g
Age :-------------years male
Sex ----------------
Residence Skathfarried
--------------------- Occupation --------------
Martial Status -------------------- Informant of the History:------------------------------
Presenting Complaints:
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of breath 5
Shortness
for days
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History of the present illness:----------------------------------------------------------------
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patent presented with severe sudden shortness
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of breath with pain in the

left side
of chest
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the pain was retired by sleeping on left
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side
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and it progressed with respiration
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Systemic Inquiry :
General:------------------------------------------------------------------------------------------
patent looked ill with distended
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abdomen
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CVS:--------------------------------------------------------------------------------------------
HTN
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Respiratory:------------------------------------------------------------------------------------
shortness of breath
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GIT:----------------------------------------------------------------------------------------------
liver cirrrchsis t Acitis
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Renal:--------------------------------------------------------------------------------------------
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NAD
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CNS:--------------------------------------------------------------------------------------------
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NAD
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Skin: --------------------------------------------------------------------------------------------
NAD
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Locomotor:-------------------------------------------------------------------------------------
NAD
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Endocrine:--------------------------------------------------------------------------------------
D M
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Past Medical History:-------------------------------------------------------------------------
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AT N D M liver cirrhosis
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Drug History:----------------------------------------------------------------------------------
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Severe use of analgesic
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Durrites
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drugs for his HTN DM
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Social History:---------------------------------------------------------------------------------
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No data
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Family History:--------------------------------------------------------------------------------
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not clear
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Clinical Examination: General Examination :----------------------------------------------
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Distended Abdomen
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pleuritic chest pain
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Vital Signs:-------------------------------------------------------------------------------------
65
T 36.40 Bp 136
10
 IIR 77

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CVS: --------------------------------------------------------------------------------------------
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NAD
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Respiratory system :---------------------------------------------------------------------------
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chest was dull on percussions with
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pleuritic rub
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Abdominal Examination:---------------------------------------------------------------------
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Positive shifting dullness
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CNS Examination:----------------------------------------------------------------------------
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MAD
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Locomotor System:---------------------------------------------------------------------------
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MAD
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Endocrine:--------------------------------------------------------------------------------------
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HAIL 4 5
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Skin ----------------------------------------------------------------------------------------------
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Acanthosis nigricans
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Other Local examinations: -------------------------------------------------------------------
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NAD
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Provisional Diagnosis:------------------------------------------------------------------------
liver Cirrhosis DM H TN
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Plan for investigations:-----------------------------------------------------------------------
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CBC LET RFT CX R
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Result of Investigations: ---------------------------------------------------------------------
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XR Showed pleural effusions on LT Side
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LFT ire increased
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Patient History and Examination Summary:-----------------------------------------------
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Say male presented HER with SOB
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for the last 5 days her had ten cirrhosis
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he also had DMT HTN before
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his liner cirrhosis caused plural
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effusions
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Final Diagnosis:-------------------------------------------------------------------------------
pleural effusions duets then cirrhosis
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Plan of Treatment: ----------------------------------------------------------------------------
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Admit PT
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duritic centers
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pleural
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Drugs given: ------------------------------------------------------------------------------------
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Lasix 80 ing
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Aldartmore 20
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Alberich mg
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Follow Up:--------------------------------------------------------------------------------------
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Outcome and Other Remarks:---------------------------------------------------------------
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not
yet
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Name of Doctor:
Signature/stamp: