A 40 YEAR OLD WITH SHORTNESS OF BREATH

 

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

A40 year-old female came to the causality with chief complaints of shortness of breath  since 1 week

 

 

HISTORY OF PRESENTING ILLNESS

·         The patient was apparently asymptomatic 7 days ago, when she developed shortness of breath 1 week back (grade 2 NYHA classification). It was insidious in onset and gradually progressive in nature and attained a present state (grade 4 NYHA classification).

·        It was associated with occasional dry cough, generalized weakness and occasional palpitations.

·        She has no complains of fever, sore throat, loss of taste and smell.

PAST HISTORY

 

•         She is a known case of diabetes since  years for which she is on regular medication.
•         She is not a known case of hypertension, TB, Asthma and epilepsy.
•      RAT for COVID-19 was negative

 

DRUG HISTORY

·        Glimepiride

·        Metformin

For the past 6 years.

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 conscious, coherent and cooperative. She is well oriented to time, place and person.

She 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: Afebrile

·         Pulse: 98 beats/mins

·         Blood pressure: 100/80 mmHg

·         Respiratory rate: 32 cycles/min

·         SpO2: 58% at room air

 

SYSEMIC EXAMINATION

 

CVS

·         S1 and S2 heart sounds heard.

·         No murmurs heard.

Respiratory system

·         Bilateral air entry +

 

·        Decreased breath sounds on right side

 

 

CNS

Intact

Abdomen

·         Soft and non-tender.

·         Bowel sounds were heard.

·         No organomegaly.

 

 

 

INVESTIGATIONS

LFT

·         Total bilirubin: 0.90 mg/dl

·         Direct bilirubin: 0.20 mg/dl

·         SGOT: 13 IU/L

·         SGPT: 13 IU/ L

·         ALP: 299 IU/L

·         Total proteins: 7.5 gm/dl

·         Albumin: 3.0 gm/dl

·         A/G ratio: 0.66

 

RFT

 

·         Blood urea: 43 mg/dl

·         Serum creatinine: 0.6 mg/dl

·         Uric acid: 3.6 mg/dl

·         Calcium: 9.6 mg/dl

·         Phosphorus: 3.8 mg/dl

·         Sodium: 134 mEq/L

·         Potassium: 4.6 mEq/L

·        Chloride: 96 mEq/L

Haemoglobin: 10.33 gm/dl

PCV: 32.5

MCV: 65.2

MCH: 20.7

MCHC: 31.7

RDW-CV: 16.4

RDW-SD: 40.6

RBC: 4,99,000 cells/cubic meter

Blood picture: microcytic hypochromic blood smear

TLC: 12,100

·         Neutrophils: 84

·         Lymphocytes: 10

·         Monocytes: 3

·         Eosinophils: 3

Platelets: 4,00,000

ABG

X-ray.

 

 

ECG

 

 HR-CT

Treatment given (day1)

1. Propped up posture 
2. O2 inhalation (To maintain saturation’s >/= 94% ) 
3. IVF 1.NS 1.RL @ 75ml/hr 
4. Inj Augmentin 1.2gm IV TID 
5. INJ PAN 40mg IV od 
6. Inj clexane 40mg s/c OD
7. Candid mouth paint 
8. GRBS CHARTING 6th hourly
9. Inj human actrapid insulin s/c 

 8am-2pm-8pm  

Treatment given (day2)

1. Propped up posture 
2. O2 inhalation (To maintain saturation’s >/= 94% ) 
3. IVF 1.NS 1.RL @ 75ml/hr 
4. Inj Augmentin 1.2gm IV TID 
5. INJ PAN 40mg IV od 
6. Inj clexane 40mg s/c OD 
7. Tab Bactrim DS (800/160mg)PO OD
8. TAB FLUCONAZOLE 150mg PO OD
9. TAB PREDNISOLONE 40mg PO OD FOR 5 days f/b Tab prednisolone 40mg OD FOR 5 days followed by Tab prednisolone 20mg OD FOR 21 days 
10. Candid mouth paint 
11. GRBS CHARTING 6th hourly
12. Inj human actrapid insulin s/c 

 8am-2pm-8pm

A 38-year-old male 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 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)

HbA1c: 6.9%

X-ray.

ECG

HR-CT

CO-RAD grade IV 

CT severity score: 8/25- mild

GRBS MONITORING 

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 8^th hourly.

·         Inj. Clexane 40mg sc OD

·         Inj. Remedisivir 200mg IV stat 100mg IV OD

·         GRBS charting 8^th hourly

·         Intermittent BIPAP at physicians’ call

·         Monitor temperature, SpO2, PR, BP 4^th 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 8^th 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 8^th hourly

·         Intermittent BIPAP at physicians’ call

·         Monitor temperature, SpO2, PR, BP 4^th 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 12^th hourly and mucomyst 8^th 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 8^th hourly

·         Intermittent BIPAP at physicians’ call

·         Monitor temperature, SpO2, PR, BP 4^th 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 12^th hourly and mucomyst 8^th 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 8^th hourly

·         Intermittent BIPAP at physicians’ call

·         Monitor temperature, SpO2, PR, BP 4^th hourly.

 Spirometry, prone positioning.

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 12^th hourly and mucomyst 8^th 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 4^th hourly.

 Spirometry, prone positioning.

 Tab. METFORMIN 500mg PO/BD

 Tab. GLIMEPRIDE 0.5 mg PO/BD