Case Discussion on Viral Pneumonia Secondary to COVID-19

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  A 38 Y/O Male with Viral Pneumonia Secondary to COVID-19


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.




CHIEF COMPLAINTS

A 38 year old male patient, was admitted in COVID ICU with the following chief complaints: 

  • Fever since 2 weeks
  • Difficulty in breathing since 7 days.


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic two weeks back. Then he developed the following:

  • Fever which was insidious in onset, low grade, intermittent type, not associated with chills and rigors.  
  • Developed Grade 2 type of dyspnea one week back with no aggravating or relieving factors and associated symptoms
  • No history of cough, expectoration, chest pain or discomfort
The patient got tested for COVID-19, 16 days back on 4th of May 2021 via Rapid Antigen Test and was stated positive.


HISTORY OF PAST ILLNESS

  • The patient is a K/C/O Hypertension and is on medication.
  • Not a K/C/O Diabetes, Asthma, Thyroid dysfunction, tuberculosis or any other Chronic Illnesses

PERSONAL HISTORY 

  • Diet : Mixed
  • Appetite : Normal
  • Sleep : Inadequate 
  • Bowel and Bladder movements : Regular
  • No addictions
  • No allergies

FAMILY HISTORY

  • Non significant 
  • No history of COVID contact among the patient's family members

DRUG HISTORY

  • Patient is on Anti-Hypertensive Treatment

GENERAL EXAMINATION

  • The patient is conscious, coherent and cooperative
  • Moderately built and well nourished
  • Pallor : Absent
  • Icterus : Absent
  • Cyanosis : Absent
  • Clubbing : Absent
  • Lymphadenopathy : Absent
  • Edema : Absent

 SYSTEMIC EXAMINATION

  1. RESPIRATIOY SYSTEM : Normal Vesicular Breath Sounds Audible
  2. CVS : S1 and S2 Heard
  3. PA : Soft, No Tenderness, No Hepatomegaly or Splenomegaly
  4. CNS : Intact


RIGHT HAND



LEFT HAND



LEGS




ABDOMEN




VITALS : 

        AT THE TIME OF ADMISSION (17-05-21)

  • PULSE : 97BPM
  • BLOOD PRESSURE: 130/60 mm Hg
  • AFEBRILE SPO2 : 92% ON RA
    


INVESTIGATIONS
  • RENAL FUNCTION TEST 


                           
INTERPRETATION : NORMAL




  • LIVER FUNCTION TEST


INTERPRETATION : Hypoalbuminemia 

  • D-DIMER




INTERPRETATION : D-Dimer elevated


  • COMPLETE BLOOD PICTURE




INTERPRETATION : NORMAL



  • ARTERIAL BLOOD GAS ANALYSIS 




INTERPRETATION : Low O2 Saturation 


AP VIEW OF CHEST


INTERPRETATION : Visible Caridomegaly

TPR GRAPH SHEET





DI
AGNOSIS :

VIRAL PNEUMONIA SECONDARY TO COVID-19 INFECTION



TREATMENT

  • O2 Inhalation to maintain SPO2 > 90%
  • IVF at 75ml/Hr
  • Tab. PAN 40mg/PO/OD 
  • Tab. MVT PO/OD
  • Tab. LIMCEE PO/OD
  • Tab. DOLO 650mg/PO/SOS
  • Inj. DEXAMETHASONE 8mg/IV/OD
  • Tab. TELMA H (40/12.5)/PO/OD
  • DUOLIN+BUDECORT NEB 6th hourly
  • SYP GRILINCTUS /PO/10ml-10ml-10ml
  • GRBS Monitoring every 6th hourly 


       VITALS AT THE TIME OF DISCHARGE (19-05-21)

  • PULSE : 86BPM
  • BLOOD PRESSURE : 130/60 mm Hg
  • AFEBRILE SPO2 : 99% ON RA

     ADVICE AT DISCHARGE 

  • Tab. PAN 40mg/PO/ 1-0-0 for 1 week
  • Tab. MVT/PO/ 0-1-0 for 1 week
  • Tab. LIMCEE /PO/ 0-1-0 for 1 week
  • Tab. DOLO 650mg/PO/SOS
  • Tab. TELMA H (40/12.5)/PO/1-0-0 for 1 week
  • SYP GRILINCTUS /PO/ 10ml-10ml-10ml
  • INCENTIVE SPIROMETRY 






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