Covid case Report
E.RISHITHA REDDY
ROLL.NO-30
“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 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 inputs on the comment box is welcome."
I've been given this case, in an attempt to understand the topic of "patient clinical data analysis" and to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations as well as to come up with a diagnosis and treatment plan.
Case Report
A 46-year-old female, who had come to hospital.
History of presenting illness-
presented with a chief complaint of fever since 1week.
she also gives a history of productive cough since 1week.
she developed dyspnea at rest since a day . Loss of apatite is present since a week.
Her SpO2-93%on RA and PR-112bpm
And was tested to be Rapid Antigen positive for COVID-19 5days back
She was in a home isolation since 5 days and was already been on tab.DOXY , tab.IVERMECTIN tab.AZITHROMYCIN,tab.ECOSPRIN and tab.WYSOLONE 10 mg for 3days.
.
PERSONAL HISTORY
Diet: Mixed
Appetite: Loss of apatite since a week
Sleep: Disturbed
Bowel, bladder: Regular
No addictions
DRUG HISTORY
No known drug allergies.
FAMILY HISTORY
No significant Family history.
None of his family members are tested COVID positive
GENERAL EXAMINATION
The patient is conscious, coherent, cooperative and well oriented to time place and person
She is sitting comfortably on the bed. She is moderately built and well nourished
PALLOR - Absent
ICTERUS - Absent
CYANOSIS - Absent
CLUBBING- Absent
LYMPHADENOPATHY -Absent
EDEMA - Absent
VITALS AND INVESTIGATIONS AND PLAN OF TREATMENT:
On 10/5/21:
Rx-
1) O2 supplementation
2)IVF 20NS 10DNS@ 75ml /hr with 1ampule of optineuron
3)tab.DOLO650mg/PO/OD
4)tab.LIMCEE/PO/OD
5)tab.PANTOP 40mg/PO/BBF
8am—-*—-*
6)Encourage plenty of oral fluids
7)Syrup Ambroxyl 10 ml/PO/TID with 1glass of water
8)Monitor Vitals
On 11/5/21:
On physical examination her :
PR-110 bpm
BP-130/70 mm of hg
SpO2-98% with 6lit of O2
Temp-98F
Rx-
1) O2 supplementation
2)IVF 20NS 10DNS@ 75ml /hr with 1ampule of optineuron
3)tab.DOLO650mg/PO/OD
4)tab.LIMCEE/PO/OD
5)tab.PANTOP 40mg/PO/BBF
8am—-*—-*
6)Encourage plenty of oral fluids
7)Syrup Ambroxyl 10 ml/PO/TID with 1glass of water
8)Monitor Vitals
9)inj.CLEXANE 40mg S.C OD
10)tab .MVT OD
INVESTIGATIONS ADVISED-
RT-PCR
On 12/5/21:
On physical examination her
Patient-conscious and coherent
PR-114 bpm
BP-120/70
SpO2-90-98%. of 10lit of O2
Temp-97F
Rx-
1) O2 supplementation
2)IVF 20NS 10DNS@ 75ml /hr with 1ampule of optineuron
3)tab.DOLO650mg/PO/OD
4)tab.LIMCEE/PO/OD
5)tab.PANTOP 40mg/PO/BBF
8am—-*—-*
6)Encourage plenty of oral fluids
7)Syrup Ambroxyl 10 ml/PO/TID with 1glass of water
8)Monitor Vitals
9)inj.CLEXANE 40mg S.C OD
10)tab .MVT OD
INVESTIGATIONS ADVISED-
Glycated haemoglobin
On 13/5/21:
On physical examination her
Patient-conscious and coherent
PR-102bpm
BP-120/70
SpO2-90. of 10lit of O2
Temp-98.4F
Rx-
1) O2 supplementation
2)IVF 20NS 10DNS@ 75ml /hr with 1ampule of optineuron
3)tab.DOLO650mg/PO/OD
4)tab.LIMCEE/PO/OD
5)tab.PANTOP 40mg/PO/BBF
8am—-*—-*
6)Encourage plenty of oral fluids
7)Syrup Ambroxyl 10 ml/PO/TID with 1glass of water
8)Monitor Vitals
9)inj.CLEXANE 40mg S.C OD
10)tab .MVT OD
11)tab.AUGMENTIN 625mg BD
12) tab.DEXAMETHASONE 8mg
On 14/5/21:
On physical examination her
Patient-conscious and coherent
PR-78 bpm
BP-120/70
SpO2-90. of 10lit of O2
Temp-98.4F
Rx-
1) O2 supplementation and Nebulisation with budecort 6th hrly
2)IVF 20NS 10DNS@ 75ml /hr with 1ampule of optineuron
3)tab.DOLO650mg/PO/OD
4)tab.LIMCEE/PO/OD
5)tab.PANTOP 40mg/PO/BBF
8am—-*—-*
6)Encourage plenty of oral fluids
7)Syrup Ambroxyl 10 ml/PO/TID with 1glass of water
8)Monitor Vitals
9)inj.CLEXANE 40mg S.C OD
10)tab .MVT OD
11)tab.AUGMENTIN 625mg BD
12) tab.DEXAMETHASONE 8mg
INVESTIGATIONS ADVISED-
D-dimer
CRP
On 15/5/21:
On physical examination her
Patient-conscious and coherent
PR-103bpm
BP-120/70mm hg
SpO2-86%of 15lit of O2
Temp-afebrile
Rx-
1) O2 supplementation and Nebulisation with budecort 6th hrly
2)IVF 20NS 10DNS@ 75ml /hr with 1ampule of optineuron
3)tab.DOLO650mg/PO/OD
4)tab.LIMCEE/PO/OD
5)tab.PANTOP 40mg/PO/BBF
8am—-*—-*
6)Encourage plenty of oral fluids
7)Syrup Ambroxyl 10 ml/PO/TID with 1glass of water
8)Monitor Vitals
9)inj.CLEXANE 40mg S.C OD
10)tab .MVT OD
11)tab.AUGMENTIN 625mg BD
12) tab.DEXAMETHASONE 8mg
SYSTEMIC EXAMINATION
RS - Normal vesicular breath sounds heard
CVS- s1 and s2 heard. No added murmurs
PA- Soft and non tender. No organomegaly
CNS- Intact
LOCAL EXAMINATION
No external injuries or scars seen
INVESTIGATIONS
REPORTS FROM HOSPITAL-
1. General investigations-
RFT, LFT,LDH,D-dimer,complete urine examination
LDH- higher than normal
RFT-
LFT-
D-dimer-
COMPLETE URINE EXMINATION-
Provisional Diagnosis
Viral pneumonia secondary to COVID
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