Tondapu Sreelekha,
8th semester
Roll no. – 135
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.
Following is the
view of my case: (history as per date of admission)
CASE
A
38-year-old male came to the OPD with chief complaints of shortness of breath since 3 days , fever since 3 days, cough
since 1 day and chest pain since 1 day
HISTORY OF PRESENTING ILLNESS
·
The patient was apparently
asymptomatic 7 days ago, when he was tested COVID positive (RAT test).
·
He complains of shortness of
breath since 3 days (grade IV). Which progressed since morning.
·
He developed fever 3 days ago
which was insidious in onset. It was of high grade, continuous type and was not
associated with chills and rigors.
·
He developed cough 1 day ago which
was productive. The sputum was scanty and mucoid in consistency.
·
He also complains of chest pain since 24hrs.
He has no complaints of loss of smell or taste, diarrhoea, headache.
PAST HISTORY
·
No similar complaints in the
past.
·
He has received the second
dose of COVAXIN 15 days back.
·
He is not a known case of diabetes,
hypertension, TB, Asthma and epilepsy
DRUG HISTO RY
·
Tab. Doxycycline
·
Tab. Ivermectin
·
Inj. Enoxaparin
·
Tab. Dabigatran 100mg OD
·
Tab. Dolo 650mg
· Tab. Limcee
Since 5 days
PERSONAL HISTORY
·
DIET- Mixed
·
APPETITE- normal
·
SLEEP- Adequate
·
BOWELS- Regular
·
MICTURATION- Normal
·
ADDICTIONS- None
·
ALLERGIES- None
FAMILY HISTORY
·
There
is no significant family history.
·
No other
member of his family have tested COVID positive.
GENERAL EXAMINATION
The patient was conscious,
coherent and cooperative. He is well oriented to time, place and person.
He is moderately built and is moderately nourished.
·
No pallor
·
No icterus
·
No cyanosis
·
No clubbing
·
No generalized
lymphadenopathy
·
No pedal
oedema
VITALS at the time of admission
·
Temperature:
febrile
·
Pulse: 78
beats/mins
·
Blood pressure:
120/80 mmHg
·
Respiratory
rate: 32 cycles/min
·
SpO2: 85%
at room air
SYSEMIC EXAMINATION
CVS
·
S1 and
S2 heart sounds heard.
·
No murmurs
heard.
Respiratory system
·
Bilateral
air entry +
·
He has bilateral
crepts on auscultation in bilateral IMA, IAA and ISA areas.
CNS
Intact
Abdomen
·
shows
truncal obesity
·
Soft and
non-tender.
·
Bowel sounds
were heard.
·
No organomegaly.
INVESTIGATIONS
LFT
·
Total bilirubin: 1.07 mg/dl
·
Direct bilirubin: 0.28 mg/dl
·
SGOT: 21 IU/L
·
SGPT: 21 IU/ L
·
ALP: 157 IU/L
·
Total proteins: 6.6 gm/dl
·
Albumin: 3.7gm/dl
·
A/G ratio: 1.28
RFT
·
Blood urea : 27 mg/dl
·
Serum creatinine : 0.9 mg/dl
·
Uric acid: 2.7 mg/dl
·
Calcium : 9.6 mg/dl
·
Phosphorus : 3.1 mg/dl
·
Sodium : 134 mEq/L
· Potassium : 4.3 mEq/L
Chloride : 98mEq/L
Haemoglobin: 16.2gm/dl
TLC: 23,400
·
Neutrophils: 91
·
Lymphocytes:5
·
Monocytes:3
·
Eosinophils: 1
Platelets: 2,78,000
D-dimer: 220
CRP: 2.4 mg/dl (positive)
X-ray.
ECG
HR-CT
Provisional Diagnosis: VIRAL PNEUMONIA SECONDARY TO COVID-19. Diabetic?.
Treatment given:
DAY 5 OF ILNESS
·
Head end elevation
·
O2 supplementation. Maintain SpO2 >92%
·
Inj. Dexamethasone 8mg IV OD
·
Inj. Pantop 40mg IV/OD
·
Tab. DOLO 650mg
·
Tab. limcee
·
IVF 20 ns @ 75ml/hr with 1amp optineuron
·
Syrup Ascoril 10ml TID
·
Nebulization with Duolin, budecort and mucomyst 8th
hourly.
·
Inj. Clexane 40mg sc OD
·
Inj. Remedisivir 200mg IV stat 100mg IV OD
·
GRBS charting 8th hourly
·
Intermittent BIPAP at physicians’ call
·
Monitor temperature, SpO2, PR, BP 4th
hourly.
VITALS ( day 6 of illness)
·
Temperature:
97.5 F
·
Pulse: 120
beats/mins
·
Blood pressure:
120/70 mmHg
·
Respiratory
rate: 22 cycles/min
·
SpO2: 87%
at room air, 94% at 5L NRM
Treatment given on day 6 of illness
·
Head end elevation
·
O2 supplementation. Maintain SpO2 >92%
·
Inj. Dexamethasone 8mg IV OD
·
Inj. Pantop 40mg IV/OD
·
Tab. DOLO 650mg
·
Tab. limcee
·
IVF 20 ns @ 75ml/hr with 1amp optineuron
·
Syrup Ascoril 10ml TID
·
Nebulization with Duolin, budecort and mucomyst 8th
hourly.
·
Inj. Clexane 40mg sc OD
·
Inj. Remedisivir 200mg IV stat 100mg IV OD
·
Tab. AZEE 500mg OD
·
2% betadine gargles diluted in a glass of water
3-4 times a day.
·
GRBS charting 8th hourly
·
Intermittent BIPAP at physicians’ call
·
Monitor temperature, SpO2, PR, BP 4th
hourly.
VITALS ( day 7 of illness)
·
Temperature:
97.8F
·
Pulse: 110
beats/mins
·
Blood pressure:
120/70 mmHg
·
Respiratory
rate: 24 cycles/min
·
SpO2: 96%
in 15L NRM
Treatment given on day 7 of illness
·
O2 supplementation. Maintain SpO2 >92%
·
Inj. Dexamethasone 8mg IV OD
·
Inj. Pantop 40mg IV/OD
·
Tab. DOLO 650mg
·
Tab. limcee
·
IVF 20 ns @ 75ml/hr with 1amp optineuron
·
Syrup Ascoril 10ml TID
·
Nebulization with Duolin8th hourly , budecort 12th
hourly and mucomyst 8th hourly.
·
Inj. Clexane 40mg sc OD
·
Inj. Remedisivir 200mg IV stat 100mg IV OD
·
Tab. AZEE 500mg OD
·
2% betadine gargles diluted in a glass of water
3-4 times a day.
·
GRBS charting 8th hourly
·
Intermittent BIPAP at physicians’ call
·
Monitor temperature, SpO2, PR, BP 4th
hourly.
VITALS ( day 8 of illness)
· Temperature: afebrile
· Pulse: 110 beats/mins, regular
· Blood pressure: 130/90 mmHg
· Respiratory rate: 24 cycles/min
· SpO2: 98% on RA
GRBS:
Treatment given on day 8 of illness
· O2 supplementation. Maintain SpO2 >92%
· Inj. Dexamethasone 8mg IV OD
· Inj. Pantop 40mg IV/OD
· Tab. DOLO 650mg
· Tab. limcee
· IVF 20 ns @ 75ml/hr with 1amp optineuron
· Syrup Ascoril 10ml TID
· Nebulization with Duolin8th hourly , budecort 12th hourly and mucomyst 8th hourly.
· Inj. Clexane 40mg sc OD
· Inj. Remedisivir 100mg IV OD
· Tab. AZEE 500mg OD
· 2% betadine gargles diluted in a glass of water 3-4 times a day.
· GRBS charting 8th hourly
· Intermittent BIPAP at physicians’ call
· Monitor temperature, SpO2, PR, BP 4th hourly.
VITALS ( day 9 of illness)
· Temperature: afebrile
· Pulse: 104 beats/mins, regular
· Blood pressure: 110/80 mmHg
· Respiratory rate: 22 cycles/min
· SpO2: 98% on RA
GRBS:
Treatment given on day 9 of illness
· O2 supplementation. Maintain SpO2 >92%
· Inj. Dexamethasone 8mg IV OD
· Inj. Pantop 40mg IV/OD
· Tab. DOLO 650mg
· Tab. limcee
· IVF 20 ns @ 75ml/hr with 1am2p optineuron
· Syrup Ascoril 10ml TID
· Nebulization with Duolin8th hourly , budecort 12th hourly and mucomyst 8th hourly.
· Inj. Clexane 40mg sc OD
· Inj. Remedisivir 100mg IV OD
· Tab. AZEE 500mg OD
· 2% betadine gargles diluted in a 2glass of water 3-4 times a day.
· GRBS monitoring
· Intermittent BIPAP at physicians’ call
· Monitor temperature, SpO2, PR, 2BP 4th hourly.
Spirometry, prone positioning.
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