A 40 years old male patient with viral pneumonia secondary to Covid- 19

Sahithi Nalabolu, 

8th semester.

Roll no:96

                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 centred 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. 

Case discussion 

 

A 40 years old male came to opd on 22/5/21 with chief complaints of  fever since 3 days ,shortness of breath since 3 days ; cough since 3 days.

History of present illness :

Patient was apparently asymptomatic 1 week back when he was tested (RAT) Covid - 19 positive. 

He developed fever since 3 days which was insidious in onset; high grade, continuous, not associated with chills and rigors. 

Shortness of breath since 3 days Grade-4. 

Cough since 3 days which was productive cough and sputum was  scanty and mucoid in consistency. 

 

He has no complaints of loss of taste or smell , headache.

Past history:

No similar complaints in past.

Not a known case of Diabetes; hypertension, TB;Asthma; epilepsy. 

Personal history: 

Diet - mixed

·         APPETITE- normal

·         SLEEP- Adequate

·         BOWELS- Regular

·         MICTURATION - Normal

·         ADDICTIONS- None

·         ALLERGIES- None 

      Family history:

     There is no significant family history.

·         No other member of his family have tested COVID positive.

 

GENERAL EXAMINATION

The patient was conscious, coherent and cooperative. He is well oriented to time, place and person.

He is moderately  built and is moderately nourished.

·         No pallor

·         No icterus

·         No cyanosis

·         No clubbing

·         No generalized lymphadenopathy

·         No pedal oedema

               VITALS 

VITALS at the time of admission 22/3/2021

·         .         Temperature: febrile
·         Pulse:  110 beats/mins
·         Blood pressure: 120/70 mmHg
·         Respiratory rate: 28 cycles/min
·         SpO2: 80% at room air

VITALS on 23/5/2021:

·         Temperature: 96 F

·         Pulse: 101 beats/mins

·         Blood pressure: 120/80 mmHg

·         Respiratory rate: 22 cycles/min

·         SpO2: 96% on 10L O2.

.         GRBS 180 mg/dl 

VITALS on 24/5/2021:

·         Temperature: 97.5 F

·         Pulse: 99 beats/mins

·         Blood pressure: 110/80 mmHg

·         Respiratory rate: 28 cycles/min

·         SpO2: 97% with 12L NRM 

VITALS on 25/5/2021:

·         Temperature: 98.6 F

·         Pulse: 106 beats/mins

·         Blood pressure: 120/60 mmHg

·         Respiratory rate: 24 cycles/min

·         SpO2: 97% on 10 L NRM, 85% on RA.

.         GRBS - 221 mg/dl

VITALS on 26/5/2021:

·         Temperature: 98.6.F

·         Pulse: 116 beats/mins

·         Blood pressure: 120/90 mmHg

·         Respiratory rate: 28 cycles/min

·         SpO2: 92% on 10 L NRM.

.         GRBS - 139 mg/dl

VITALS on 27/5/2021:

·         Temperature: afebrile

·         Pulse: 118 beats/mins

·         Blood pressure: 110/80 mmHg

·         Respiratory rate: 24 cycles/min

·         SpO2: 95% on 12 L NRM, 88% on RA.

.         GRBS -  180 mg/dl

VITALS on 28/5/2021:

·         Temperature: afebrile

·         Pulse: 125 beats/mins

·         Blood pressure: 110/80 mmHg

·         Respiratory rate: 24 cycles/min

·         SpO2: 92% on 12 L NRM, 80% on RA.

.         GRBS -  124 mg/dl

VITALS on 29/5/2021:

·         Temperature: afebrile

·         Pulse: 105 beats/mins

·         Blood pressure: 110/70 mmHg

·         Respiratory rate: 24 cycles/min

·         SpO2: 92% on 12 L NRM.

.         GRBS -  106 mg/dl

SYSEMIC EXAMINATION

CVS:

·         S1 and S2 heart sounds heard.

·         No murmurs heard.

Respiratory system:

·         Bilateral air entry +

·         He has bilateral crepts on auscultation in bilateral IMA, IAA

CNS:

Intact

Abdomen

·         Soft and non-tender.

·         Bowel sounds were heard.

·         No organomegaly.

       Clinical picture:

  

     Investigations:

ECG:

HRCT :

Provisional Diagnosis:  

VIRAL PNEUMONIA SECONDARY TO COVID-19.

Treatment Regimen on 22/5/2021 ( day 3 of illness):

. Head end elevation
. O2 supplementation. Maintain SpO2 > 92%
· Inj. Dexamethasone 8mg IV OD
· Inj. Pantop 40mg IV/OD
· Tab. DOLO 650mg
· Tab. limcee
· IVF 20 ns @ 75ml/hr with 1amp optineuron
· Syrup Ascoril 10ml TID
· Nebulization with Duolin, budecort and mucomyst 8th hourly.
· Inj. Clexane 40mg sc OD
· Inj. Remedesivir 200mg IV stat 100mg IV OD
· GRBS charting 8th hourly

Treatment Regimen on 23/5/2021(day 4 of illness):

· Head end elevation

· O2 supplementation. Maintain SpO2 >92%

· Inj. Dexamethasone 8mg IV OD

· Inj. Pantop 40mg IV/OD

· Tab. DOLO 650mg

· Tab. limcee

· IVF 20 ns @ 75ml/hr with 1amp optineuron

· Syrup Ascoril 10ml TID

· Nebulization with Duolin, budecort and mucomyst 8th hourly.

· Inj. Clexane 40mg sc OD

· Inj. Remedesivir 200mg IV stat 100mg IV OD.

. tab. AZITHRO 500mg od.

. tab. montek-Lc

. 10 unit insulin.

· GRBS charting 8th hourly

· Intermittent BIPAP at physicians’ call

· Monitor temperature, SpO2, PR, BP 4th hourly.

Treatment given on 24/5/2021( Day 5 of illness):

· Head end elevation

· O2 supplementation. Maintain SpO2 >92%

· Inj. Dexamethasone 8mg IV OD

· Inj. Pantop 40mg IV/OD

· Tab. DOLO 650mg

· Tab. limcee

· IVF 20 ns @ 75ml/hr with 1amp optineuron

· Syrup Ascoril 10ml TID

· Nebulization with Duolin, budecort and mucomyst 8th hourly.

. inj. HAI 8U

· Inj. Clexane 40mg sc OD

· Inj. Remedesivir 200mg IV stat 100mg IV OD.

· GRBS charting 8th hourly

· Intermittent BIPAP at physicians’ call

· Monitor temperature, SpO2, PR, BP 4th hourly.

Treatment given on 25/5/2021(day 6 of illness):

. Head end elevation

· O2 supplementation. Maintain SpO2 > 92%

· Inj. Dexamethasone 8mg IV OD

· Inj. Pantop 40mg IV/OD

· Tab. DOLO 650mg

· Tab. limcee

· IVF 20 ns @ 75ml/hr with 1amp optineuron

· Syrup Ascoril 10ml TID

· Nebulization with Duolin8th hourly , budecort 12th hourly and mucomyst 8th hourly.

. inj. HAI 8U

· Inj. Clexane 40mg sc OD

· Inj. Remedesivir 200mg IV stat 100mg IV OD

· GRBS charting 8th hourly

· Intermittent BIPAP at physicians’ call

· Monitor temperature, SpO2, PR, BP 4th hourly.

Treatment given on 26/5/2021 (Day 7 of illness):

. Head end elevation

· O2 supplementation. Maintain SpO2 > 92%

· Inj. Dexamethasone 8mg IV OD

· Inj. Pantop 40mg IV/OD

· Tab. DOLO 650mg

· Tab. limcee

· IVF 20 ns @ 75ml/hr with 1amp optineuron

· Syrup Ascoril 10ml TID

· Nebulization with Duolin8th hourly , budecort 12th hourly and mucomyst 8th hourly.

· Inj. Clexane 40mg sc OD

· Inj. Remedesivir 200mg IV stat 100mg IV OD

· GRBS charting 8th hourly

· Intermittent BIPAP at physicians’ call

· Monitor temperature, SpO2, PR, BP 4th hourly.

Treatment given on 27/5/2021(Day 8 of illness):

. Head end elevation

· O2 supplementation. Maintain SpO2 > 92%

· Inj. Dexamethasone 8mg IV OD

· Inj. Pantop 40mg IV/OD

· Tab. DOLO 650mg

· Tab. limcee

· IVF 20 ns @ 75ml/hr with 1amp optineuron

· Syrup Ascoril 10ml TID

· Nebulization with Duolin8th hourly , budecort 12th hourly and mucomyst 8th hourly.

. inj. HAI 2U

· Inj. Clexane 40mg sc OD

· Inj. Remedesivir 200mg IV stat 100mg IV OD

· GRBS charting 8th hourly

· Intermittent BIPAP at physicians’ call

· Monitor temperature, SpO2, PR, BP 4th hourly.

.  Spirometry, prone positioning.

Treatment given on 28/5/2021  (Day 9 of illness):

. Head end elevation

· O2 supplementation. Maintain SpO2 > 92%

· Inj. Dexamethasone 8mg IV OD

· Inj. Pantop 40mg IV/OD

· Tab. DOLO 650mg

· Tab. limcee

· IVF 20 ns @ 75ml/hr with 1amp optineuron

· Syrup Ascoril 10ml TID

· Nebulization with  budecort  and mucomyst 8th hourly.

· Inj. Clexane 40mg sc OD

.inj.Ceftriaxone-1gm/iv/bd

· GRBS charting 8th hourly

· Intermittent BIPAP at physicians’ call

· Monitor temperature, SpO2, PR, BP 4th hourly.

.  Spirometry, prone positioning.

Treatment given on 29/5/2021  (Day 10 of illness):

· O2 supplementation. Maintain SpO between 92- 95%.

· Inj. Dexamethasone 8mg IV OD

· Inj. Pantop 40mg po OD

· Tab. DOLO 650mg

· Tab. limcee po od

.Tab.zincovit po od

· IVF 20 ns @ 75ml/hr with 1amp optineuron

· Syrup Ascoril 15ml po hs 

· Nebulization with  budecort 8hourly .

· Inj. Clexane 40mg sc bd

.inj.Ceftriaxone-1gm/iv/bd

· GRBS monitoring daily @ 8am

· Intermittent BIPAP 

· Monitor temperature, SpO2, PR, BP 4th hourly.

.  Spirometry, prone positioning.

.Patient discharged on LAMA.

Discharge summary

I would like to thank Dr.Rakesh biswas sir for giving me this opportunity and   Dr. Sai Charan sir for the guidance.