Medicine case discussion

     A 57year old male with viral pneumonia secondary to COVID19;

Name; k.shirisha

Rollno: 60

8th semester

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 centered 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. 

A 57 year old male with viral pneumonia secondary to covid19

Following is the view of my case;

Case;

A 57 year old male patient occupation by Rmp doctor resident of miryalaguda came to the opd on11-05-21 with chief complaints of; 

Loss of appetite since 3 days

Occasional Non productive cough since 3days 

Body pains since  3days

He got tested for Rapid antigen test positive for Covid19 1 week back

History of present illness ;

The patient was apparently asymptomatic 1 week ago then   he got tested for RAT positive for covid 19. then he  presented with loss of appetite since 3 days associated with non productive cough which was occasional

Body pains since 3 days

History of past illness ;

He is known case of Type2 diabetes mellitus since 10 years

No history of hypertension,asthma, tuberculosis,stroke,or heart diseases

Treatment history; 

For diabetes injection Insulin was taken

Personal history; 

Diet; mixed

Appetite ; decreased since3 days

Boweland bladder movements : regular

Sleep; adequate

Addictions; no

Family history ;

Not significant

General examination ;

The patient is conscious , coherent, cooperative well oriented to time ,place,person.he is sitting comfartably on bed.well built and nourished

Pallor ; absent

Icterus ; absent

Cyanosis ;absent

Clubbing ;absent

Edema ;absent

Lymphadenopathy ;absent

Vitals; 

Temperature ;Afebrile

Pulserate; 102bpm

Spo2 ;92%onRoom air

Blood pressure ; 120/70mmhg

Systemic examination ;

Cardiovascular system;

S1,S2 heart sounds are heared

No murmurs or thrills are heared

Abdominal examination

Soft,nontender

No visible pulsations ,no organomegaly

Central nervous system; 

Level of consciousness ; conscious

Speech; normal

Investigations;

On11-05-21

LFT;

SGOT ;67IU/L

SGPT; 53IU/L

ALP ;142

Totalproteins ; 5.6

Albumin ; 3.4

FBS; 210mg/dl

Hb; 14.3 gm/dl

TLC; 6,600

CRP; 2.4mg/dl

D-dimers ;100ng/ml

LDH ;449Iu/L

Rt- pcr done

Chest xray was done

ECG done

Vitals;

Temperature ;96°F

Pulserate ;80bpm

Blood pressure ; 120/70mmhg

Spo2; 85-90%on room air

Provisional diagnosis ;

Covid19 pneumonia

Treatment ; (11-05-21,11:45 )

1) O2 supplementation, maintain Spo2>92%

2) IVF 20NS @75ml/hour with 1 ampoule OPTINEURON

3)Tab; Dolo650 mg po/ sos

4)Tab ; Limcee po/OD

5) Tab; PANTOP 40mg / po/ OD( 8 am)

6) injection HUMAN Actrapid insulins/c

according to sliding scale

8am-2pm-8pm

7) Encourage plenty of oral fluids 

8)GRBS charting 6th hourly

8am-2pm-8pm-2am

9) moniter vitals 

Shifted to Covid Amc

11/05/21

1) O2 supplementation, maintain Spo2>90%

2) IVF 20NS @75ml/hour with 1 ampoule OPTINEURON

3)Tab; Dolo650 mg po/ sos

4)Tab ; Limcee po/OD

5) Tab; PANTOP 40mg / po/ OD( 8 am)

6) injection HUMAN Actrapid insulins/c

according to sliding scale

8am-2pm-8pm

7) Encourage plenty of oral fluids 

8)GRBS charting 6th hourly

8am-2pm-8pm-2am

9) moniter vitals

10)DUOLIN Budecort/Nebulization 6th hourly

11) syrup; Grillincterus 15ml po /BD

On12/05/21

O/E; patient is conscious coherent

Vitals ;

Pulse rate ;88bpm

Bp; 110/79mmHg

Spo2 ; 92% on room air

             99% with 5 litres of oxygen

Temperature ;98.6°F

Treatment;

1) O2 supplementation, maintain Spo2>90%

2) IVF 20NS @75ml/hour with 1 ampoule OPTINEURON

3)Tab; Dolo650 mg po/ sos

4)Tab ; Limcee po/OD

5) Tab; PANTOP 40mg / po/ OD( 8 am)

6) injection HUMAN Actrapid insulin ,4units/ TID

according to sliding scale

8am-2pm-8pm

7) Encourage plenty of oral fluids 

8)GRBS charting 6th hourly (8am-275,1pm-304,8pm-288)

8am-2pm-8pm-2am

9) moniter vitals

10)DUOLIN Budecort/Nebulization 6th hourly

11) syrup; Grillincterus 15ml po /BD

On 13-05-21

Vitals; 

PR; 106bpm

BP ; 110/70mmhg

Spo2 ;91-92% on6 litres of O2

Fio2 ; 60% 

Adviced awake proning

Treatment;

1) O2 supplementation, maintain Spo2>90%

2) IVF 20NS @75ml/hour with 1 ampoule OPTINEURON

3)Tab; Dolo650 mg po/ sos

4)Tab ; Limcee po/OD

5) Tab; PANTOP 40mg / po/ OD( 8 am)

6) injection HUMAN Actrapid insulins/c

according to sliding scale

8units- 8units-8units

7) Encourage plenty of oral fluids 

8)GRBS charting 4th hourly (8am-201,1pm-296,8pm-236)

9) moniter vitals

10)DUOLIN Budecort/Nebulization 6th hourly

11) syrup; Grillincterus 15ml po /BD

On 14-05-21

Vitals; 

PR ; 82bpm

BP; 120/80mmhg

Temperature; 98.7°F

Spo2 ; 90-95%on room air

            >95% with 5litres of oxygen

Treatment;

1) O2 supplementation, maintain Spo2>90%

2) IVF 20NS @75ml/hour with 1 ampoule OPTINEURON

3)Tab; Dolo650 mg po/ sos

4)Tab ; Limcee po/OD

5) Tab; PANTOP 40mg / po/ OD( 8 am)

6) injection HUMAN Actrapid insulins/c

according to sliding scale

10units-10units-10units

7) Encourage plenty of oral fluids 

8)GRBS charting 4th  hourly (8am -234mg/dl)

9) moniter vitals

10)DUOLIN Budecort/Nebulization 6th hourly

11) syrup; Grillincterus 15ml po /BD

Patient get discharged on 14/05/21.

 I would like to Thank  Dr.Rakesh Biswas sir,  for giving me this opportunity