A 63 YEAR OLD FEMALE WITH VIRAL PNEUMONIA SECONDARY TO COVID-19
MIRYALA KALPANA
ROLL NO. 83
MBBS ,8th semester
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.
Following is the view of my case.......
CASE-1:
A 63 year old female came to the OPD on 2nd of May with chief complaints of
· 1.Generalised weakness since 7 days
· 2. Dry cough since 1 day
HIHISTORY OF PRESENTING ILLNESS :
PaPatient was apparently asymptomatic 14 days back
T she developed fever of duration 7 days which is insidious in onset,high grade ,continuous in nature without chills/rigors
along with loose motions since 7 days
She was tested positive for COVID-19 on 27th April,2021
She then got admitted to HOSPITAL-1 where she received treatment symtomatically for covid-19 but on the request of patient's attender she was discharged on 29th April,2021
She got admitted to HOSPITAL-2 [present hospital] with
-Generalised weakness which is insidious in onset,gradual in progression with no aggravating factors
-Dry cough which is insidious in onset,intermittent in nature with no diurnal variation and postural variations
-fever and loose motions relieved prior to admission
No complaints of shortness of breath,palpitations,sweating, loss of smell and taste
PAST HISTORY :
K/C/O Diabetes mellitus [type 2] since 5 years on medications [oral antihyperglycemic drugs]
but since 1week on inj. H.mixtard/sc
No history of HTN,Asthma,TB,Epilepsy,CVA
No surgical history
FAMILY HISTORY :
No significant family history
PERSONAL HISTORY :
Married
Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and Bladder movements -normal
Addiction-none
Allergies-none
DRUG HISTORY:
Takes oral antihyperglycemic drugs since 5years but inj.H.mixtard since 1 week
DRUGS PRESCRIBED BY OUTSIDE HOSPITAL DURING DISCHARGE[29/04/21]
- tab.fabiflu 800mg
- tab.faropenem 200mg
- tab.PAN D
- tab.premed
- tab.apixaban 2.5 mg
- tab.zincovit
- tab.ascor 500mg
- tab.montus
- tab.atocor 40mg
- ascoril syp
GENERAL EXAMINATION
Patient was examined in well lit room with informed consent.
She is conscious,coherent,and cooperative
well oriented to time ,place and person
- Pallor-absent
- Icterus-absent
- Cyanosis-absent
- Clubbing-absent
- Lympadenopathy-absent
- Edema-absent
VITALS:
On the day of admission - 02/5/2021
- Temperature-99 F
- Pulse Rate-82 beats per minute
- Blood pressure-130/90 mmhg
- Respiratory rate-20 cycles/minute
- spo2-86% at room air
- 96% at 4 litres of O2
03/5/2021
- Temperature-98.4 F
- Pulse Rate-82 beats per minute
- Blood pressure-130/90 mmhg
- Respiratory rate-20 cycles/minute
- spo2-95% at 4 litres of O2
04/05/2021
- Temperature-98.6 F
- Pulse Rate-72 beats per minute
- Blood pressure-110/80 mmhg
- Respiratory rate-22 cycles/minute
- spo2-95% at 4 litres of O2
06/05/2021
- Temperature-94.2 F
- Pulse Rate-82 beats per minute
- Blood pressure-110/80 mmhg
- Respiratory rate-20cycles/minute
- spo2-97% at 4 litres of O2
07/05/2021
- Temperature-97.6 F
- Pulse Rate-86 beats per minute
- Blood pressure-110/80 mmhg
- Respiratory rate-20cycles/minute
- spo2-94% at room air
SYSTEMIC EXAMINATION:
Respiratory system-normal vesicular breath sounds heard
bilateral air entry present
Cardiovascular system-S1 and S2 heard, no murmurs
Perabdomen-obese,soft,no tenderness ,no organomegaly
Central nervous system- intact
INVESTIGATIONS
Done at the time of admission
1.Complete blood picture
hb-11.5 gm/dl
wbc count-14,100cells/cumm
platelet count-2.21 lakhs/cumm
2.Liver function tests- normal
3.Renal function test-
Urea-42mg /dl
serum creatinine-1.3mg/dl
sodium-139mEq/dl
Potasium-4.0mEq/dl
chloride-96mEq/dl
4. LDH -560 units/L [normal range:35-214units/L]
5 .D.dimer -970 ng/ml [normal range:80-500ng/ml]
6. serum ferritin -382 ng/ml [normal range:11-306ng/ml]
7. GRBS monitoring-
GRBS-325 mg/dl on 02/5/2021
GRBS-250 mg/dl on 03/5/2021
GRBS-262 mg/dl on 04/05/2021
GRBS-190 mg/dl on 06/05/2021
GRBS-190 mg/dl on 07/05/2021
7 . ECG
periperally than central in distribution
Moderate VIP CORADS -5 ,CTSI -9/25
- Temperature-97.6 F
- Pulse Rate-86 beats per minute
- Blood pressure-110/80 mmhg
- Respiratory rate-20cycles/minute
- spo2-94% at room air
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