COVID case discussion
K.Keshitha , MBBS 8th semsester
Roll No : 64
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we discuss our individual patients problems through series of inputs from available
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problems with collective current best evidence based inputs .This E log book
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I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history , clinical findings , investigations and come up with diagnosis and treatment plan .
A 50 YEAR OLD MALE WITH VIRAL PNEUMONIA SECONDARY TO COVID
CASE :
A 50 year old male came to hospital on 20/5/21 with CHIEF COMPLAINS of :
Fever since 1 week
Dry cough since 1 week
Shortness of breath since 1 week
Nausea since 1 week
Decreased appetite since 1 week
HISTORY OF PRSENTING ILLNESS :
Patient was apparently asymptomatic 1 week back and then he
developed :
Fever which was insidious in onset
, low grade,continuous ,not associated with chills and rigor and relieved on
taking medication.
Cough which is incidious in onset gradually progressive without diurnal variation and it is non productive
in nature
Shortness of breath which was insidious in onset ,gradually progressive.
It is associated with
nausea and decreased appetite since 1 week.
He tested positive for SARS COV 2 on 20/5/21
No complains of loss of smell or taste ,chest pain,sore
throat ,head ache, palpitations
PAST HISTORY :
Not a k/c/o HTN,DM,Asthma,epilepsy,TB.
Surgical history : None
PERSONAL HISTORY :
Appetite : Decreased since 1 week
Diet : Mixed
Bowel and bladder movements : Regular
Sleep : Adequate
No addictions
No allergies.
FAMILY HISTORY :
No significant family history.
GENERAL EXAMINATION :
Patient is conscious , coherent and cooperative and well
oriented to time , place and person.
He is moderately built and moderately nourished.
Pallor : Absent
Icterus : Absent
Cyanosis : Absent
Clubbing : Absent
Lymphedenopathy :
Absent
Edema : Absent
VITALS : Temp - Afebrile
PR - 102 bpm
BP - 100/60 mmhg
SPO2 - 89% onRA
INVESTIGATIONS :
Hb – 12.6gm/dl
TLC – 12,000cells/cu
mm
Neutrophils :
90
Lymohocytes : 06
Eosinophils : 02
Monocytes : 02
Platelets – 2.63 lakh/cu mm
LIVER FUNCTION TESTS :
Total
bilirubin : 0.72 mg/dl
Direct
bilirubin : 0.20 mg/dl
AST : 40 IU/L
ALT :56
IU/L
Alkaline phosphate :144 IU/L
Total
proteins : 6 gm/dl
Albumin : 3.3 gm/dl
A/G
ratio : 1.30
RENAL FUNCTION TESTS :
Urea : 50
mg/dl
Creatinine :
1.2 mg/dl
Uric acid :
5.9 mg/dl
Calcium : 9.9
mg/dl
Phosphorous : 2 mg/dl
Sodium
: 138 mEq/L
Potassium : 4.1 mEq/L
Chloride : 97 mEq/L
CRP : 2.4 mg/dl
LDH levels : 420 IU/lit
D-DIMER levels : 100 ng/ml
ESR : 90
ECG :
Interpretation : Right bundle branch block.
PROVISIONAL DIAGNOSIS :
Viral pneumonia secondary to COVID 19
Right bundle branch block.
ON DAY OF HOSPITALIZATION :
VITALS : Temp – Afebrile
Pulse –
102 bpm
BP –
100/60 mm hg
SPO2 - 89% on RA
TREATMENT : O2 inhalation with face mask
IVF 1 unit NS @ 100ml/hr with optineurin
Tab PAN- D 40mg PO OD
Tab DOLO 650mg PO SOS
Tab MVT PO OD
Tab LIMCEE PO OD
Incentive spirometry
DUOLIN
,BUDECORT, MUCOMIST nebulization 6th hourly
Syp
GRILLINCTUS 10ml TID PO
Inform SOS
Temperature , PR , BP
charting
GRBS
charting 6th hourly
ON 2ND DAY OF
HOSPITALIZATION :
VITALS : Temp – Afebrile
PR –
90/min
BP –
110/70 mmhg
SPO2 –
94%
GRBS –
127 mg/dl
TREATMENT : O2
inhalation to maintain SPO2 >90%
IVF 1 unit NS @ 100ml/hr with optineurin
Tab PAN- D 40mg PO OD
Tab DOLO 650mg PO SOS
Tab MVT PO OD
Tab LIMCEE PO OD
Incentive spirometry
DUOLIN ,BUDECORT, MUCOMIST nebulization 6th hourly
Syp GRILLINCTUS 10ml TID PO
Inform SOS
Inj DEXAMETHASONE 6mg/IV/OD
Temperature , PR , BP charting
GRBS charting 6th hourly
ON 3RD DAY OF
HOSPITALIZATION :
VITALS : Temp – 98.6F
PR – 94
BP –
120/70 mmhg
SPO2 –
92%RA
GRBS – 143
mg/dl
TREATMENT : O2
inhalation to maintain SPO2 >90%
IVF 1 unit NS @ 100ml/hr with optineurin
Tab PAN- D 40mg PO OD
Tab DOLO 650mg PO SOS
Tab MVT PO OD
Tab LIMCEE PO OD
Incentive spirometry
DUOLIN , MUCOMIST nebulization
8th hourly , BUDECORT nebulization 12th hourly
Syp GRILLINCTUS 10ml TID PO
Inform SOS
Inj DEXAMETHASONE 6mg/IV/OD
Temperature , PR , BP charting
GRBS charting 6th hourly
Inj CLEXANE 40mg SC OD
ON 4TH DAY OF HOSPITALIZATION
:
VITALS : Temp – 98.6F
PR –
94bpm
RR – 26 cycles/min
GRBS –
114 mg/dl
SPO2 – 96%
on RA
TREATMENT : O2 inhalation to maintain SPO2
>90%
IVF 1 unit NS @ 100ml/hr with optineurin
Tab PAN- D 40mg PO OD
Tab DOLO 650mg PO SOS
Tab MVT PO OD
Tab LIMCEE PO OD
Incentive spirometry
DUOLIN , MUCOMIST nebulization 8th hourly , BUDECORT nebulization 12th
hourly
Syp GRILLINCTUS 10ml TID PO
Inform SOS
Inj DEXAMETHASONE 6mg/IV/OD
Temperature , PR , BP charting
GRBS charting 6th
hourly
Inj CLEXANE 40mg SC OD
ON 5TH DAY OF
HOSPITALIZATION :
VITALS : Temp – Afebrile
PR – 84bpm
BP –
110/60 mmhg
GRBS –
121 mg/dl
SPO2 –
96% on RA
TREATMENT : O2 inhalation
to maintain SPO2 >92%
IVF 1 unit NS @ 100ml/hr with optineurin
Tab PAN- D 40mg PO OD
Tab DOLO 650mg PO SOS
Tab MVT PO OD
Tab LIMCEE PO OD
Incentive spirometry
DUOLIN , MUCOMIST nebulization 8th hourly , BUDECORT nebulization 12th
hourly
Syp GRILLINCTUS 10ml TID PO
Inform SOS
Inj DEXAMETHASONE 6mg/IV/OD
Temperature , PR , BP charting
GRBS charting 6th hourly
Inj CLEXANE 40mg SC OD
ADVICE AT DISCHARGE :
Tab
APIXABAN 5mg/PO/OD
Tab PAN
40mg PO OD
Tab
MVT OD
Tab
Limcee OD
Incentive spirometry
Syp
ASCORIL 10ml/PO/TID
I would like to thank Dr.Rakesh Biswas sir for giving me this oppurtunity and Dr.Vamshi sir for guidance.
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