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
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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