COVID CASE REPORT

 

E.RISHITHA REDDY

ROLL .NO-30

MEDICINE CASE DISCUSSION

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 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

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.

A 42YEAR OLD FEMALE PATIENT WITH A HISTORY OF SOB-

Following is the view of my case :   (Admitted on 13/05/21 , 9 pm)

CASE REPORT-

A 42year old female patient came with a history of high grade

 fever 10 days back , SOB since 3days on exertion  , cough 

productive since 2days and has chest pain since 3days

HISTORY OF PRESENTING ILLNESS-

Patient  complained that she has a high grade , intermittent 

fever 10 days back. Then she developed SOB which is of 

sudden in onset and progressive on exertion . SOB is 

associated with chest pain which is intermittent  since 2 days  

On exertion.She also has cough since 2 days. It is associated

 with sputum in small quantity. 

And RAT was done in COVID OPD and tested positive.

Her SpO2 levels are 82% on RA

Pulse rate -124bpm

She was advised admission 

PAST HISTORY-

She is a known case of hypothyroidism since 4 years. And on 

Tab. Thyronorm 100mcg O.D

SURGICAL HISTORY-

She has a history of hysterectomy 20years back.

PERSONAL HISTORY :

Diet - mixed

Appetite - decreased

Bowel and bladder habits - regular

Sleep - inadequate

FAMILY HISTORY-

No significant family history.

GENERAL EXAMINATION-

The patient is conscious coherent well oriented to time place 

and person and sitting comfortably on bed moderately built 

and well nourished.

PALLOR- absent 

ICTERUS -absent 

CYANOSIS- absent 

CLUBBING- absent 

LYMPHADENOPATHY - absent 

EDEMA- absent 

VITALS-

Temperature- Afebrile

PR-94bpm

BP- 120/90mm hg

SpO2- 99% with 5litres of O2

SYSTEMIC EXAMINATION-

CVS- S1 S2 heard . No added Murmurs

PA- soft and non tender ,  No organomegaly 

CNS-intact

Respiratory system- Normal vesicular breath sounds heard

INVESTIGATIONS-

CBP-

Hb-12.7gm%

TC-5,700

DC-N80 L15 E 02 M03 B00

DLC-1.5lakh/mm3

D-dimer-10ng/ml

Serology-

LDH-571

CRD-2.4mg/dl(positive)

HRCT-

CT score-16/25

 LFT AND RFT-

ECG-

FASTING BLOOD SUGAR-

On 13/5/21-

On 14/5/21-

TRP graphic chart-

PROVISIONAL DIAGNOSIS-

COVID-19 pneumonia with a known case of hypothyroidism.

Rx-

1.head end elevation

2.O2 inhalation to maintain SpO2 >92%

3.Tab.Dexamethasone 8mg I.v/TID

4.Tab.PANTOP 40 mg/I.v/OD

 5.Tab. LIMCEE /PO/OD

  6.Tab.PCM 650mg PO/SOS

7.Encourage plenty of oral fluids.

8.Tab.Thyronorm 100mcg /OD at 7:00am

Half an hour before breakfast 

9.MONITOR VITALS

10.Nebulisation budecort 8th hrly

11.Inj.HAI 10U/SC

GRBS 6th hrly

15.BP,PR,SpO2 monitoring