"This is an online E logbook to discuss our patient's de-identified health data shared after taking
his/her/guardian's signed informed consent. Here, we discuss our individual
patient's problems through series of inputs from the available global online
community of experts with an aim to solve those patient's clinical problems
with collective current best evidence-based inputs".
This E logbook also
reflects my patient-centered online learning portfolio and your valuable
comments in the comment box are welcome.
___________________________________________________________________________________________________________
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 a diagnosis and treatment plan.
Following is the
view of my case: (history as per date of admission)
CASE
A
72-year-old male came to the OPD with chief complaints of shortness of breath, fever
and low oxygen levels.
HISTORY OF PRESENTING ILLNESS
·
The patient was apparently
asymptomatic 3 days ago, when he developed shortness of breath (grade IV- NYHA classification ) which was insidious
in onset, and rapid in progression with no aggravating factors.
·
He also developed a fever 3
days ago which was insidious in onset. It was of high grade, intermittent and
was not associated with chills and rigors.
·
He did not have any complaints
of cough, chest pain, loss of smell or taste, diarrhoea, headache.
PAST HISTORY
·
No similar complaints in the
past.
·
He is a known
case of hypertension for the past 20 years. Currently under treatment (Tablet Losar-H
50/12.5 mg and Tablet Cinod 20mg)
PERSONAL HISTORY
·
DIET- Mixed
·
APPETITE- Lost
·
SLEEP- Adequate
·
BOWELS- Regular
·
MICTURATION- Normal
·
ADDICTIONS- None
·
ALLERGIES- None
FAMILY HISTORY
·
There
is no significant family history.
·
No other
member of his family has been 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 moderately nourished.
·
No pallor
·
No icterus
·
Central and peripheral cyanosis is present
·
No clubbing
·
No generalized
lymphadenopathy
·
No pedal oedema
VITALS
·
Temperature:
febrile
·
Pulse:
104 beats/mins
·
Blood pressure:
130/80 mmHg
·
Respiratory
rate: 24 cycles/min
·
SpO2: 85%
at 15 Lit of O2
SYSTEMIC EXAMINATION
CVS
·
S1 and
S2 heart sounds heard.
·
No murmurs
heard.
Respiratory system
·
Trachea
is central in position.
·
The patient
is dyspneic and wheeze is present.
·
Tubular
breath sounds heard.
·
Crepts were
heard.
CNS
Intact
Abdomen
·
Soft and
non-tender.
·
Bowel sounds
were heard.
·
No organomegaly.
INVESTIGATIONS
LFT
- Total bilirubin : 0.76 mg/dl
- Direct bilirubin : 0.27 mg/dl
- SGOT : 31 IU/L
- SGPT : 18 IU/ L
- ALP : 130 IU/L
- Total proteins : 5.8gm/dl
- Albumin: 303gm/dl
- A/G ratio: 1.31
RFT
·
Blood urea : 38 mg/dl
·
Serum creatinine : 1.2 mg/dl
·
Uric acid: 4.8 mg/dl
·
Calcium : 9.7 mg/dl
·
Phosphorus : 2.6 mg/dl
·
Sodium : 136 mEq/L
·
Potassium : 3.7 mEq/L
·
Chloride : 102 mEq/L
ABG
·
pH - 7.28
·
pCO2 – 29.3mm Hg
·
pO2 – 45.4 mm Hg
· HCO3 – 21.6 mmol/L
·
BEB - –0.7 mmol/L
·
BEecf - –1.4 mmol/L
·
TCO2 – 43.9 VOL
·
O2 Sat – 83.6%
Haemoglobin: 11.3gm/dl
Ferritin: 254 mcg/L
TLC: 13,300 cells/microL
CRP: 2.4 mg/dl (positive)
X-ray
ECG
Provisional Diagnosis: VIRAL PNEUMONIA SECONDARY TO COVID-19 {severe}
Treatment given:
Inj. Pan 40mg IV OD
Inj. Dexamethasone 8mg IV TID
IVF 10 ns optineuron, 10rl thiamine @ 100ml/hr
Tab. Dolo 650mg p/o TID
Head end elevation to 30 degree
GRBS charting 6th hourly
Intermittent BIPAP at physicians’ call
Nebulization with duolin, budecort, mucomyst 8th hourly.
Monitor temperature, SpO2, PR, BP 4th hourly.
No comments:
Post a Comment