MEDICINE CASE DISCUSSION

 A 70 year old female patient with viral pneumonia secondary to covid 19

June 12th 2021

Bhavani Akula

8th semester 

roll.no-150

 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. 

CASE DISCUSSION

CHIEF COMPLIANTS

A70 year old female came to opd on 11/5/2021with chief compliants of

> fever since 5 days

>dry cough since 5 days

>shortness of breath since 3 days

>generalised weakness since 3 days

HISTORY OF PRESENT ILLNESS

Patient was apparantly asymptomatic 5days back

>Then she developped fever since 5 days,which is rapidly progressive

>cough since 5 days,which is dry in nature

>tested (rapid antigen test)-covid 19 positive -3days back

>shortness of breath since 3 days-grade 3

>generalised weakness since 3 days

PAST HISTORY

Known case of- Hypertension since 2 years

>Diabetes mellitus since 2 years

Not a known case of Asthma,TB,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 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

        

     VITALS AT THE TIME OF ADMISSION(11/5/2021)

·       >Temperature-Febrile

      >Pulse-97beats/min

     

     >Blood pressure-120/80mmHg

     >Spo2-93% at 16 lit of O2 

      

     VITALS ON (11/5/2021) (4.50 PM)

  >Temperature-98 F

       >Pulse-92beats/min

     

      >Blood pressure-110/60mmHg

      >Spo2-99% at 15lit of O2 

      VITALS ON (12/5/2021) (8AM)

      >Temperature-Afebrile

      >Pulse-92beats/min

     

     >Blood pressure-130/90mmHg

     >Spo2-94% at 15 lit of O2 

     >GRBS-338mg/dl

     VITALS ON (13/5/2021)

       >Temperature-98 F

      >Pulse-112beats/min

     

     >Blood pressure-120/80mmHg

     >Spo2-85% at 16 lit of O2 

     VITALS ON (13/5/2021) (4.13PM)

      >Pulse-57beats/min

     

     >Blood pressure-160/80mmHg

      

     >Respiratory rate-60/min

     >Spo2 73% at 16 lit of O2 

    SYSTEMIC EXAMINATION

    =>Cardio vascular  system: S1,S2 are heard.No murmurs are heard.

    =>Respiratory system:

      

      >Dysppnoea,Wheeze present

      >Position of trachea-central

      >Breath sounds-vesicular

      >Adventitious sounds-Rhonchi

     =>Per Abdomen: Soft,Non-tender,No organomegaly

    =>CNS Examination: Intact

      PROVISIONAL DIAGNOSIS

,

       Viral pneumonia secondary to covid-19 with Type2 DM,HTN

      

     

      TREATEMENT HISTORY (11/5/2021)

     1)Head end elevation

      

     2)O2 inhalation to maintain Spo2>90%

     3)IVF-NS-With Optineuron 50ml/hr

     4)Inj.Dexamethasone 8mg IV/OD

     5)Inj.Pantop 40mg IV/OD

     6)Inj.Clexane 40mg SC.OD

     7)Duolin Budecort/Nebulization 6th hrly

     8)Tab.MVT OD

     9)Tab.Vit C OD

     10)GRBS 4th hourly

     11)Temp charting 4th hrly

     12)PR,BP,SpO2 monitoring hourly

     TREATEMENT HISTORY (12/5/2021)

     1)O2 inhalation-Maintain SpO2>92%

     2)IVF-NS-cont.infusion with 1 ampule of Optineuron

     3)Inj.Dexamethasone-8mg IV/OD

     4)Inj.Pantop-40mg/IV/OD

     5)Inj.Clexane-40mg/SC/OD

     6)Nebulisation with Duolin-6th hrly

     7)T.MVT-PO/OD

     8)T. Limcee-PO/OD

     9)Temp.charting 4th hrly

    10)Monitor vitals

    11)GRBS 4th hrly

    12)Inj.HAI according to slicing scale

    13)BP monitoring 4th hrly

    14)Tab.Olkem-40

    TREATMENT HISTORY (13/5/2021)

     1)O2 inhalation maintain SpO2>90%

     2)IVF-NS-cont.infusion with 1amp of Optineuron

     3)Inj.Dexamethasone 8mg/IV/OD

    4)Inj. Pantop 40mg/IV/OD   

     

    5)Inj. Clexane 40mg/SC/OD

    

    6) Nebulization with Duolin 6th hrly

    7)T. MVT - PO/OD

    8)T. Limcee- PO/OD

    

    9)Temp. charting 4th hrly

    10)Monitor vitals

    11)GRBS monitoring 4th hrly

    12)Inj. HAI according to sliding scale

    13)BP, PR, SpO2 monitoring

    14)T. Omlesartan 40mg OD

S

    Syp. Cactulose  15ml

     

    Immediate cause of death- Type 2 Respiratory failure

    Antecedent cause of death-Severe covid-19 pneumonia

     

    

    INVESTIGATIONS

    ECG :

      

 

       

     

     

    D-dimer, RFT, LFT, ABG, CRP, CBP:

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     I would like to thank Dr.Rakesh Biswas Sir for giving me this opportunity and

        Dr.Kranthi Mam for the guidance

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