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
- RESPIRATIOY SYSTEM : Normal Vesicular Breath Sounds Audible
- CVS : S1 and S2 Heard
- PA : Soft, No Tenderness, No Hepatomegaly or Splenomegaly
- CNS : Intact
RIGHT HAND
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
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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