GENERAL MEDICINE CASE DISCUSSION

A 38 YEAR OLD MALE WITH FEVER AND SHORTNESS OF BREATH.

 D.Shivani 

Roll no.25
8 th semester
Date:23-05-2021

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 under guidance of Dr.Sai Charan sir.


CASE SCENARIO.


A 38 year old male patient came to the OPD on 17/05/2021 with chief complaints of

FEVER SINCE 14 DAYS

GENERALIZED BODY WEAKNESS SINCE 8 DAYS

SHORTNESS OF BREATH SINCE 7 DAYS


HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 14 days back then he developed

-Fever which was insidious in onset.Intermettent in nature not associated with chills and rigors and there were no aggrevating and releiving factors.

-Generalized body weakness which was insidious in onset gradual in progression .He was tested positive for rapid antigen covid on 4-05-2021(HRCT CHEST CORADS 6,CTSI 14/25) . 

- He developed Grade 2 shortness of breath(NYHA CLASSIFICATION) 7 days back which was insidious in onset  and gradual in progression.

There is no history of loss of taste and smell chest pain , vomiting , cough chest pain or head ache.


The patient got tested for covid-19 via RTPCR and was stated positive.


 PAST HISTORY 


  • The patient is a K/C/O Hypertension since 3 years and is on medication.
  • Not a K/C/O ;Diabetes,Asthma,Tuberculosis,and any other chronic illnesses.

PERSONAL HISTORY

  • Diet : Mixed
  • Appetite : Normal
  • Sleep : Adequate
  • Bowel and Bladder movements : Regular
  • No Addictions
  • No allergies
FAMILY HISTORY:Not Significant
DRUG HISTORY
  • Patient is on Anti-Hypertensive Treatment.
  • Took 6 doses of remedesvir injection for covid -19 infection.
GENERAL EXAMINATION :
 
The patient is examined with informed consent.
Patient is consious,coherent,cooperative,is well oriented to time,place,person.
He is Moderately Built and nourished.

Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent

VITALS:

On the day of admission- 17/05/2021
Temperature-98° F
Heart Rate - 97 beats/min
Blood Pressure - 130/70 mm Hg
Respiratory rate - 18 cycles/min
SPO2 - 92% at room air
GRBS - 115 MG/DL

18/05/2021

Temperature - afebrile
Heart rate - 83 beats/min
Blood pressure - 120/80 mm Hg
SPO2 - 96% at room air

19-05-2021

Temperature - afebrile
Heart rate - 84 beats/min
Blood pressure - 110/70 mm Hg
SPO2 - 96% at room air


SYSTEMIC EXAMINATION :

CVS - S1 and S2 heard
            No added thrills,murmurs

RESPIRATORY SYSTEM ; Normal vesicular breath sounds heard
Dyspnoea: grade 2.

PER ABDOMEN : soft, non tender, no organomegaly

CNS : intact


INVESTIGATIONS:

COMPLETE BLOOD PICTURE 


                


LIVER FUNCTION TEST :



RENAL FUNCTION TEST :












ARTERIAL BLOOD GAS ANALYSIS:






ECG REPORT:





PROVISIONAL DIAGNOSIS: 

VIRAL PNEUMONIA SECONDARY TO COVID-19 INFECTION.


TREATMENT REGIMEN:

17/05/2021 

O2 INHALATION TO MAINTAIN SPO2>90%

Iv fluids - 1 unit NS with 1 amp of optineuron @ 75ml/hr

INJ.PANTOP 40 MG/IV/OD

TAB.DEXAMETHASONE  4MG/PO/BD

TAB.LIMCEE/PO/OD

TAB.TELMA H(40/12.5)/PO/OD

GRBS MONITORING 8TH HRLY

BP,PR,SPO2 monitoring


18/05/2021


O2 INHALATION TO MAINTAIN SPO2>90% ivfluids - 1 unit NS with 1 amp of optineuron @ 75ml/hr

INJ.PANTOP 40 MG/IV/OD

TAB.DEXAMETHASONE  4MG/PO/BD

TAB.MVT/TO/OD

TAB.LIMCEE/PO/OD 

GRBS MONITORING 8TH HRLY

BP,PR,SPO2 monitoring. 




19-05-2021


O2 INHALATION TO MAINTAIN SPO2>90%

Iv fluids - 1 unit NS with 1 amp of optineuron @ 75ml/hr

INJ.PANTOP 40 MG/IV/OD

TAB.DEXAMETHASONE  4MG/PO/BD

TAB.MVT/TO/OD

TAB.LIMCEE/PO/OD

GRBS MONITORING 8TH HRLY

BP,PR,SPO2 monitoring.



VITALS AT THE TIME OF DISCHARGE (19/05/2021)


PULSE :86BPM

BP: 130/60MM HG

Temperature:Afebrile

 Spo2:99%on room air


ADVICE AT DISCHARGE 


TAB PAN 40 MG/PO/1-0-0X 1WEEK

TAB MVT/PO/0-1-0 X 1WEEK

TAB LIMCEE /PO/0-1-0 X 1WEEK

TAB DOLO650MG/PO/SOS

TAB TELMA H(40/12.5)/PO/1-0-0X 1WEEK

SYP GRILLINCTUS /PO/10ML-10ML-10ML

INCENTIVE SPIROMETRY


Date of discharge: 19-05-2021(10:00AM)




 

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