A 65-year-old female patient with viral pneumonia secondary to COVID-19

 

Tondapu Sreelekha, 8^th semester

Roll no. – 135

 This is online E log book 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 available global online community of experts with an aim to solve those patients’ clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome

 

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 female came to the OPD with chief complaints of fever since 10 days and cough since 10 days

 

HISTORY OF PRESENTING ILLNESS

·         Patient was apparently asymptomatic 10 days back when she had fever. It was of high  grade, intermittent and not associated with chills and rigor.

·         She also had cough since 10 days. It was productive and the sputum was of scanty aamount.

PAST HISTORY

·         No similar complaints in the past.

·        She  got a RAT done 5 days back which was negative.

·        She is a known case of hypertension since 7years for which he is taking medication.

·        She is not a known case of diabetes mellitus, TB, Asthma and epilepsy

DRUG HISTROY

·         Tab. NEBIVOLOL 2.5mg/PO/OD

·         Tab. ECOSPRIN AV (75/10)mg

 

 

PERSONAL HISTORY

·         DIET- vegetarian

·         APPETITE- normal

·         SLEEP- Adequate

·         BOWELS- Regular

·         MICTURATION- Normal

·         ADDICTIONS- None

·         ALLERGIES- None

 

FAMILY HISTORY

·         There is no significant family history.

 

 

GENERAL EXAMINATION

The patient was conscious, coherent and cooperative and well oriented to time, place and person.

She was moderately built and 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: 82 beats/mins

·        Blood pressure: 110/70 mmHg

·        Respiratory rate: 16 cycles/min

·        SpO2: 93% on room air 

SYSEMIC EXAMINATION

 

CVS

·         S1 and S2 heart sounds heard.

·         No murmurs heard.

Respiratory system

·      She patient was dyspnoeic

·      Bilateral air entry +

·     Ronchi were heard.

 

CNS- Intact

Abdomen

·         Soft and non-tender.

·         Bowel sounds were heard.

·         No organomegaly.

 

INVESTIGATIONS (day 1 of hospitalization)

 

INVESTIGATIONS (day 2 of hospitalization)

 

 

Provisional diagnosis: Viral pneumonia secondary to moderate COVID-19 infection.

 

Treatment given (day1)

1.      Tab. PCM 650mg/PO/TID

2.      Syp. ASCORIL 10ml/PO/BD

3.      Neb with BUDECORT – 12^th hourly

4.      O2 inhalation @ 4lit/hr

5.      Plenty of fluids and soft diet.

6.      Tab. NEBIVOLOL 2.5mg/PO/OD

7.      Tab. ECOSPRIN AV(75/10)mg PO/HS

8.      Monitor BP, PR, SpO2 4^th hourly

Vitals (day2)

·        Temperature: afebrile

·        Pulse: 84 beats/mins

·        Blood pressure: 110/70 mmHg

·        SpO2: 96% on room air 

 

Treatment given (day2)

1.    Tab. PCM 650mg/PO/TID

2.    Syp. ASCORIL 10ml/PO/BD

3.    Neb with BUDECORT – 12^th hourly

4.    O2 inhalation @ 4lit/hr

5.    Plenty of fluids and soft diet.

6.    Tab. NEBIVOLOL 2.5mg/PO/OD

7.    Tab. ECOSPRIN AV(75/10)mg PO

8.    Monitor BP, PR, SpO2 4^th hourly

9.    Inj. CLEXANE 40mg/s.c./BD

Vitals (day3)

·        Temperature: afebrile

·        Pulse: 94 beats/mins

·        Blood pressure: 120/70 mmHg

·        GRBS: 8am: 171mg/dL; 4am: 154mg/dL

·        SpO2: 98% on FiO2 40%

 

Treatment given (day3)

1.      IVF 1 NS and 2 RL @ 150ml/hr with THIAMINE and OPTINEURON

2.      Inj. PAN 40MG/IV/OD

3.      Inj. DEXAMETHASONE 8mg/IV/OD

4.      GRBS charting 4^th hourly

5.      Inj. HAI s.c. according to the sliding scale

6.      Vitals charting 4^th hourly

7.      Tab. NEBIVOLOL 2.5mg/PO/OD

8.      Inj. CLEXANE 40mg/s.c./BD

 

Vitals (day4)

·        Temperature: afebrile

·        Pulse: 80 beats/mins

·        Blood pressure: 120/70 mmHg

·        GRBS: 171mg/dL

·        SpO2: 96% on room air 

 

Treatment given (day4)

1.      IVF 1 NS  with OPTINEURON @ 75ml/hr

2.      Inj. PAN 40MG/IV/OD

3.      Inj. DEXAMETHASONE 8mg/IV/OD

4.      GRBS charting 4^th hourly

5.      Inj. HAI s.c. according to the sliding scale

6.      Tab. NEBIVOLOL 2.5mg/PO/OD

7.      Inj. CLEXANE 40mg/s.c./BD

Vitals (day5)

·        Temperature: afebrile

·        Pulse: 74 beats/mins

·        Blood pressure: 110/80 mmHg

·        GRBS: 134mg/dL

·        SpO2: 96% on room air 

 

Treatment given (day5)

1.      O2 inhalation to maintiain SpO2 greater than 90%

2.      IVF 1 NS  with OPTINEURON @ 75ml/hr

3.      Inj. PAN 40MG/IV/OD

4.      Inj. DEXAMETHASONE 8mg/IV/OD

5.      GRBS charting 4^th hourly

6.      Inj. HAI s.c. according to the sliding scale

7.      Tab. NEBIVOLOL 2.5mg/PO/OD

On day 6 0f hospitalization, the patient was found to be stable and fit for discharge.

Treatment advice given at the time of discharge

1.      Tab. NEBIVOLOL 2.5mg/PO/OD

2.      Tab. PANTOP 40mg/PO/BD for 1 week

3.      Tab. ECOSPRIN AV(75/10)mg PO/HS

4.      Tab. LIMCEE PO/OD for 2 weeks

5.      Tab MVT PO/OD for 2 weeks

6.      Tab. APIXABAN 5mg/OD for 1 week

7.      Syp. ASCORIL 10ml/PO/BD for 4 weeks

 

 

 

 

A 38 YEAR OLD MALE PATIEN WITH DIABETIC KETOACIDOSIS WITH PSEUDO HYPONATREMIA

Tondapu Sreelekha, 8^th semester

Roll no. – 135

 This is online E log book 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 available global online community of experts with an aim to solve those patients’ clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome

 

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 4 days, right ear pain since 5 days, bilateral leg pain since 1 month, vomiting since 10 months.

 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 10 months back when he had episodes of vomiting which were ON and OFF.

Later he developed bilateral leg pain 1 month back.

He had had right ear pain for 5 days which was associated with ear discharge which was mucoid, blood stained, non foul smelling. There is no history of trauma, URTI, decreased hearing, giddiness.

He developed shortness of breath 4 days back.

PAST HISTORY

·         No similar complaints in the past.

·         He is a known case of diabetes mellitus since 1 year for which he used medication for 10 months, after which he stopped taking medication on his own and started using ayurvedic medication.

·         He is not a known case of hypertension, TB, Asthma and epilepsy

 

 

PERSONAL HISTORY

·         DIET- Mixed

·         APPETITE- normal

·         SLEEP- Adequate

·         BOWELS- Regular

·         MICTURATION- Normal

·         ADDICTIONS- None

·         ALLERGIES- None

 

FAMILY HISTORY

·         There is no significant family history.

 

 

GENERAL EXAMINATION

The patient was drowsy and had altered sensorium.

He was moderately built and  moderately nourished.

·         No pallor

·         No icterus

·         No cyanosis

·         No clubbing

·         No generalized lymphadenopathy

·         No pedal oedema

 

 

VITALS at the time of admission

·        Temperature: 98.4F

·        Pulse: 94 beats/mins

·        Blood pressure: 110/70 mmHg

·        Respiratory rate: 24 cycles/min

·        GRBS: 175mg/dL

 

SYSEMIC EXAMINATION

 

CVS

·         S1 and S2 heart sounds heard.

·         No murmurs heard.

Respiratory system

·         Bilateral air entry +

·         No crepts

 

CNS

Altered sensorium

Abdomen

·         Soft and non-tender.

·         Bowel sounds were heard.

·         No organomegaly.

 

INVESTIGATIONS

LFT

·         Total bilirubin: 1.0 mg/dl

·         Direct bilirubin: 0.2 mg/dl

·         SGOT: 26 IU/L

·         SGPT: 12 IU/ L

·         ALP: 222 IU/L

·         Total proteins: 7.1 gm/dl

·         Albumin: 3.8gm/dl

·         A/G ratio: 1.16

 

RFT

 

·         Blood urea : 39 mg/dl

·         Serum creatinine : 0.6 mg/dl

·         Uric acid: 6.7 mg/dl

·         Calcium : 10 mg/dl

·         Phosphorus : 2.1 mg/dl

·         Sodium : 130 mEq/L

·         Potassium : 3.8 mEq/L

       Chloride : 98mEq/L

 

 

Haemoglobin: 16.2gm/dl

TLC: 7,700

Urine analysis

·         Ketones: positive

·         Albumin: positive

·         Sugar: 3+

·         Pus cells: 3-4

·         Epithelial cells: 2 to 4

 

 

Provisional diagnosis: Diabetic ketoacidosis secondary to non compliance to insulin. Pseudo hyponatremia secondary to hyperglycemia.

 

Treatment given:

·         IVF NS @ 100ml/hr

·         IVF FUSIDEX @ 75ml/hr if GRBS is less than 200mg/ dl

·         Inj.  40IU HAI in 39ml NS @ 5ml/hr algorithm 2 to be followed.

·         NBM till further orders.

·         Inj. NaHCO3 50mEq IV stat followed by Inj. NaHCO3 100mEq I 200ml NS stat.

·         GRBS 6^th hourly charting.

·         Temperature 4 hourly charting

·         Strict I/O charting

·         BP/ PR/ spO2 charting 2 hourly

·         Inj. ZOSTOM 1.5gm/IV/BD

·         Tab. CLOWAZEPAM 0.5mg/PO/Stat