A 48 year male with viral pneumonia due to COVID

 This is online E log book to discuss out patients de-identified health data shared after taking his guardian`s 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 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 comments box is welcome.

      A 48 YEAR OLD MALE WITH CHIEF COMPLAINTS OF COUGH AND SHORTNESS OF BREATH SINCE 2 DAYS  CAME TO HOSPITAL ON 17TH OF MAY 

 HISTORY OF PRESENT ILLNESS

The patient was apparently asymptomatic 2days back , then developed cough and shortness of breath. Cough is sudden in onset, continues in nature and aggravated on sleep. Shortness of breath is present on daily activities also(GRADE 4). 

Patient was tested positive for COVID on 6th may and used kit given by the doctor.

HRCT-Scan was done on 12th may which has shown 40% lung involvement.

 PAST HISTORY 

-Medical history:-diagnosed as type 2 diabetic on admission 

Not a known case of hypertension , CVA, CAD, Tuberculosis, epilepsy.

Uses medications for gas problem.

His GRBS was 317mg/dl when came to the hospital.

-No significant surgical history.

 PERSONAL HISTORY 

-Diet mixed 

-Appetite normal 

-Sleep inadequate (wakes up because of cough and shortness of breath)

-Bowel and bladder regular 

-Addictions daily one-quarter 

-Food allergies - avoids dal and potatoes (because of gas problem)

-No drug allergies.

FAMILY HISTORY

Brother expired because of COVID-19 a few days back

GENERAL EXAMINATION

The patient was conscious, coherent, co-operative and well oriented to time. Patient is dyspneic.

.pallor-absent 

.icterus-absent

.cyanosis-absent

.clubbing-absent

.lymphadenopathy-absent

.edema-absent

  VITALS

.temperature-febrile 

.pulse-88bpm

.respiratory rate-24cpm

.blood pressure-110/70 mmhg

.spo2-90% at room air 

    96% on 6L of O2

   SYSTEMIC EXAMINATION 

-CVS - S1 , S2 heart sounds heard

-PA no significant observations 

-CNS

INVESTIGATIONS



 


HRCT







DIAGNOSIS:viral pneumonia due to COVID-19

TREATMENT ON 17/5

-IVF 10 NS 

-Tablet - PAN 40mg 

-Neb with DUOLIN+BUDDCORT 

-Tablet - DOLO 650mg 

-Tablet - MVT 

-Tablet - LIMCEE 

-Syrup - ASCORYL 

-Injection - DEXA 6mg 

-Injection - CLEXANE 40mg 

TREATMENT ON 18/5

-O2 inhalation 6L

-IVF 10NS

-tab PAN 40 mg

-neb with DUOLIN and BUDDCORT

-tab DOLO 650mg

-tab MVT

-tab LYMCEE

-syrup ASCORYL

-Inj DEXA 6 mg

-Inj CLEXANE 40mg 

TREATMENT ON 19/5

-O2 inhalation 5L

-IVF NS 10

-tab PAN 40mg

-tab DOLO 650mG

-tab MVT

-Tab LYMCEE

-syrup ASCORYL

- Inj DEXA 6 mg

-Inj CLEXANE 40mg


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