51 year old male patient with viral pneumonia 2⁰ to covid-19 infection


MBBS 8th semester

Name:Rithika.K

 This is an 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.

Case discussion

A 51 year old male patient came to the general medicine opd with a chief complaints of 
Loss of taste and smell since 7 days
Cough since 6 days
Shortness of breath on exertion since 3 days

History of present illness:
Patient was apparently alright one week back then he developed loss of smell and taste later he developed cough which is of productive type and white in color initially later became green 
He also developed shortness of breath on walking 
Not associated with fever 
No history of loose stools or vomitings

History of past illness:
K/C/O hypertension since 4 years 
K/C/O type 2 diabetes
No other co-morbidities

Family history: non contributory

Personal history:
Appetite : normal
Diet : mixed
Bowel and bladder : regular
No known allergies
Addictions : regular intake of alcohol 
                      Tobacco smoker

Treatment history:
Tab. Cinod t OD for hypertension
Tab. Glucoryl M1 for diabetes mellitus

Physical examination:
Patient was examined in a well lit room and the consent was taken 
Patient was concious coherent and cooperative

Vitals: (02-05-2021)
Blood pressure: 140/90 mm Hg
Pulse rate: 110 per min
Temperature: 98.6 °F
SPO2: 98% at 6 liters of O2

Systemic examination:
Cardiovascular System:
S1 and S2 heart sounds heard, no murmurs.

Respiratory System:
Dyspnea is present
Centrally placed trachea 
Normal Vesicular breath sounds heard

Per Abdomen:
Scaphoid shaped abdomen,no tenderness, no palpable mass, no organomegaly

Central Nervous System:Intact


On 03-05-2021(day 8 of symptoms)
Vitals:
Blood pressure:130/80 mmHg
Pulse rate: 84 bpm
Temperature: afebrile
SPO2: 94% on 2L of O2

GRBS: 268 mg/dl ( 8 units of HIA given)
Corad-5
CT severity-12/25


On 04-05-2021( day 9 of symptoms)
Vitals:
Blood pressure:140/70 mmHg
Pulse rate: 113bpm
Respiratory rate: 25 cpm
Temperature: 98.4°F 
SPO2: 94% on 2L of O2

GRBS: 258 mg/dl ( 3 units of Inj.HIA given s/c)
Corad-5
CT severity-12/25


On 05-05-2021(day 10 of symptoms)
Vitals:
Blood pressure:130/80 mmHg
Pulse rate: 86bpm
Temperature: afebrile
SPO2: 97%

GRBS: 250 mg/dl


On 06-05-2021
Vitals:
Blood pressure:110/70 mmHg
Pulse rate: 86bpm
Temperature: 97.2°F
SPO2: 96%

GRBS: 247mg/dl


On 07-05-2021
Vitals:
Blood pressure:130/80 mmHg
Pulse rate: 105bpm
Temperature: 98.4°F
SPO2: 95% on room air 

GRBS: 243 mg/dl


Investigations:
ECG findings

Provisional diagnosis: acute viral pneumonia secondary to covid 19 infection

Severity of covid- mild to moderate


Treatment:

Tab. AUGMENTIN 625mg

Inhalation to maintain SPO2 at >99%

Nebulization with BUDECORT 8th hourly and DUOLIN 8th hourly and MUCOMISE 12th hourly

Syrup.ASCORIL -10ml TID

Tab. PCM 650 mg

Inj.HAI Subcutaneously according to sliding scale at 8 am 1 pm and 8 pm

GRBS charting (6th hourly)

Tab.PANTOP 40 mg OD dose

Tab. CINOD-T OD dose

Monitor Temp/ BP/ PR /SPO2  2 hourly

Inj.CLEXANE 60mg subcutaneous OD dose

Tab.FLUVIR 75 mg BD


Patient was discharged on 07-05-2021 at 6:30 pm with rapid antigen test positive



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