Viral pneumonia secondary to COVID

 70 year old male with viral pneumonia secondary to COVID-19

SHIVANI THOTA, 8th sem

Roll number:134

under the guidance of Dr. Vamsikrishna ( PG -I) sir


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. 


CASE DISCUSSION 

 

 A 70 year old female homemaker by occupation presented to OPD on  4/5/2021 With 

 

  • Fever since 2 days
  • Loss of appetite since 2 days

 History of presenting illness:


Patient was apparently asymptomatic 2 days ago then she developed fever which was insidious in onset intermittent in nature not associated with chills and rigor with Loss of appetite 

  She tested positive for COVID via rapid antigen test


PAST HISTORY 

 

No similar complaints in the past


Not a known case of Hypertension,Asthma,Epilepsy,CAD


PERSONAL HISTORY 


Diet: Mixed

Appetite: Decreased 

Sleep:Adequate 

Bowel and bladder:Regular 

No addictions 

No known allergies  


DRUG HISTORY : No known drug allergies 


FAMILY HISTORY : Insignificant 


GENERAL EXAMINATION



The patient was examined in a well lit room, with informed consent.


Patient is conscious,coherent,Cooperative and is moderately built and malnourished 


Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent

Edema: Absent 


VITALS (at time of admission)

HR: 106bpm

BP: 100/60mmHg

RR: 20cpm 

Temp: 99F

SpO2: 97% on RA

SYSTEMIC EXAMINATION 


Respiratory System: Bilateral air entry positive


CVS: s1, s2 heard


CNS: intact(GCS 15/15 E4,M6,V5)


INVESTIGATIONS:

Rt pcr,cxr-PA view,hemogram,LFT,RFT,RBS,ECG,ESR,CRP

                                             LFT (4/5/2021)

          



                                         HEMOGRAM (4/5/2021)


 

                                             ESR (4/5/2021)
                                           


                                             RFT (4/5/2021)




                                            CRP (4/5/2021)




                                      BLOOD SUGAR (4/5/2021)




                                           RT-PCR(7/5/2021)



PROVISIONAL DIAGNOSIS:

Viral pneumonia secondary to COVID infection 


TREATMENT


Patient was admitted to AMC for further management and was given following drugs:

 

On 4/5/2021:

    1)IVF- 1 NS with amp THIAMINE-75ml/hr,

            1RL with 1amp OPTINEURON- 75ml/hr

2)Temperature charting 4th hourly 

Spo2 charting 4th hourly

PR and BP charting 5th hourly 

3)Tab. DOLO-650 P/O SOS
4) plenty of  oral fluids
5)inj.PAN 40m IV OD
6)O2 inhalation to maintain SPO2 >92

On 5/5/2021:
 
Vitals:(8AM)

PATIENT:conscious and coherent 
TEMPERATURE:99.8F
PR:72 bpm
BP:90/60mmhg
SPO2:97%

treatment:
1)IVF :NS  with amp THIAMINE-75ml/hr,
           RL with 1amp OPTINEURON- 75ml/hr
 2) Temperature charting 4th hourly
     SPO2 charting 4th hourly 
     PR and BP charting 6th hourly 
3) Tab. DOLO-650 P/O SOS
4) plenty of  oral fluids
5)inj.PAN 40m IV OD
6)O2 inhalation to maintain SPO2 >92

On 6/5/2021
Vitals(8AM)
 

PATIENT:conscious and coherent 
TEMPERATURE:a febrile 
PR:98 bpm
BP:120/60mmhg
SPO2:99%
GRBS:89mg/dl

Treatment 
1) IVF NS   With THIAMINE 75mg/dl
          RL with OPTINURON  75mg/dl
2)Temperature charting 4th hourly
   SPO2 charting 4th hourly 
   PR and BP charting 6th hourly 
3) Tab.DOLO-650 P/O SOS
4) plenty of  oral fluids
5)Tab.PAN 40m IV OD
6)O2 inhalation@ maintain SPO2>90%

On 7/5/2021:
Vitals (8AM):
 

PATIENT:conscious and coherent 
TEMPERATURE:98F
PR:84 bpm 
BP:90/70mmhg
SPO2:94% on 6L of O2
GRBS:105mg/dl

 Treatment :

1) IVF NS   With THIAMINE 75mg/dl
          DNS with OPTINURON  75mg/dl
2)Temperature charting 4th hourly
   SPO2 charting 4th hourly 
   PR and BP charting 6th hourly 
3) Tab. PCM 650mg/PO/OD 
4) plenty of  oral fluids
5)Tab.PANTOP 40mg/PO/OD
6)O2 inhalaton/ SOS @2-4L/min
7)SYP.AMBROLITE 2TSP  TID


On 8/5/2021:

TREATMENT 

1) IVF NS   With OPTINURON 75mg/dl
          DNS  
2)Temperature charting 4th hourly
   SPO2 charting 4th hourly 
   PR and BP charting 6th hourly 
3) Tab. PCM 650mg/PO/OD 
4) plenty of  oral fluids
5)Tab.PANTOP 40mg/PO/OD
6)O2 inhalaton/ SOS @2-4L/min
7)SYP.AMBROLITE 2TSP  TID

On 9/5/2021:
 
TREATMENT 
1) IVF NS   With OPTINURON 75mg/dl
          DNS  
2)Temperature charting 4th hourly
   SPO2 charting 4th hourly 
   PR and BP charting 6th hourly 
3) Tab. PCM 650mg/PO/OD 
4) plenty of  oral fluids
5)Tab.PANTOP 40mg/PO/OD
6)O2 inhalaton/ SOS @2-4L/min
7)SYP.AMBROLITE 2TSP  TID

On 10/5/2021:

Vitals (8AM):
 
PATIENT:conscious and coherent 
TEMPERATURE:98F
PR:93 bpm 
BP:100/60mmhg
SPO2:95% on Room air

TREATMENT
1) Temperature charting 4th hourly
   SPO2 charting 4th hourly 
   PR and BP charting 6th hourly 
2)plenty of oral fluids
3)Head end elevation 
4)O2 supplementation if SPO2<92%
5)Encourage ORS sachet in 1L of water -to be taken in small sips
6) TAB PCM 650mg/PO/OD 
7) TAB PANTOP 40mg/PO/OD
8)TAB LIMCEE
9) SYP.AMBROLITE 2TSP  TID with 1glass of water
 
PRESCRIPTION BEFORE DISCHARGE (11/5/2021)

1) plenty of oral fluids
2) Head end elevation 
3)TAB MVT ODfor 2weeks
4) TAB LIMCEE for 2weeks
5) TAB PANTOP 40mg/PO/OD 
6) SYP.AMBROLITE 2TSP 



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