58 years female patient with viral pneumonia secondary to covid-19

 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 patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.



Vignatha jampani ,8th semester

roll no: 45

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 a diagnosis and treatment plan.

Following is the view of my case:

Case: A 58 year old female patient, resident of damaticherla, came to the hospital with CHIEF COMPLAINTS of fever and cough since one week and shortness of breath since 1 day.

HISTORY OF PRESENT ILLNESS: The patient was apparently asymptomatic one week ago and she developed fever and cough which was insidious in onset, relieved by medication. It is not associated with chills, rigors, and sweating. Shortness of breath since one day and it is not associated with wheeze, and chest pain.

PAST HISTORY: 

She is a known case of hypertension since 2 years and she's on regular medication.

There is no history of diabetes, asthma and tuberculosis.

PERSONAL HISTORY:

Appetite: normal

Diet: mixed

Bowel and bladder movements: regular

Addictions: none

Sleep : adequate 

FAMILY HISTORY:

There is no significant family history.

GENERAL EXAMINATION:

The patient was conscious, coherent and cooperative, sitting comfortably on the bed.

She is well oriented to time, place and person.

She is well built and moderately nourished.

VITALS:

Temperature: afebrile (at present )

Pulse: 90 beats per minute, regular, normal in volume and character.

Blood pressure:120/80 mmhg

Respiratory rate: 40 per minute 

spo2: 88% on 16 liter of o2

No pallor 

No icterus 

No clubbing

No lymphadenopathy 

No edema

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heart sounds heard 

No murmurs 

RESPIRATORY SYSTEM:

Bilaterally symmetrical chest both sides moving equally with respiration.

bilateral air entry present

normal vesicular breath sounds

CNS:

No abnormal defects.

Abdomen: bowel sounds are heard.

INVESTIGATIONS:

COMPLETE BLOOD PICTURE:

Hemoglobin: 12.4 gm/dl

total count:15600cu/mm

differential count: neutrophils: 67

                              lymphocyes:28

                              eosinophils:3

                              monocytes:2

Random blood sugar:564mg/dl

CRP:1.2mg/dl

D-dimer:560ng/ml

serum LDH:835 IU/lit

LIVER FUNCTION TEST:

Bilirubin: 380mg/dl

Direct:0.37mg/dl

SGOT:170 IU/lit

SGPT:444 IU/lit

ALP:303 IU/lit

Total protein: 5.98 g/dl

Albumin: 3.08g/dl

RENAL FUNCTION TEST:

Blood urea:87mg/dl

serum creatinine: 0.8mg/dl

phosphorus:4.6 mg/dl

Na+:135mEq/lit

K+:4.0mEq/lit

cl-:100mEq/lit

CHEST X RAY


DIAGNOSIS:

UNCONTROLLED HYPERGLYCEMIA WITH SEVERE COVID-19 PNEUMONIA

TREATMENT:

O2 inhalation to maintain saturation 

Duoli budecart nebulization 6th hourly

Injection clexane 40mg s.c od

Injection methyl prednisolone 125mg Intravenous TID

Injection pantop 40mg IV BD

Tab MVT od 

Tab DOLO 650mg

IV fluids

Inj HAI subcutaneous

Tab Augmentin 625 BD.

She expired on 15th may in the morning. 




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