29 year old male patient with viral pneumonia secondary to COVID-19
MEDICINE CASE DISCUSSION
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May 19, 2021
29 YEAR OLD MALE PATIENT WITH VIRAL PNEUMONIA SECONDARY TO COVID-19
G Suhitha Gnaneswar , MBBS 8th semester
Roll no. 34
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 a diagnosis and treatment plan.
following is the view of my case : (history as per the date of admission)
CASE:
A 29 year old male patient came to the opd with chief complaints of shortness of breath since 2 days and cough since 2 days
HISTORY OF PRESENTING ILLNESS:
The patient was apparently asymptomatic 18 days back. Then he developed fever which was high grade and intermittent . He went to the doctor and was asked to get tested for COVID-19 . The test was positive after which the patient was in self isolation at home . He had fever for 4 days, headache for 3 days and diarrhoea for 2 days. He was given medication by the doctor after which the symptoms subsided and after 14 days of isolation he got tested again for COVID-19 which was positive . He then developed fever since 4 days, cough which was productive since 4 days and shortness of breath grade 3 since 2 days. He also had fatigue.He lost the sense of taste and smell. He then came to our opd for further assessment.
PAST HISTORY:
The patient does not have diabetes mellitus, hypertension, asthma
Surgical history-none
PERSONAL HISTORY:
Diet- mixed
Appetite-decreased
Sleep-inadequate
Bowel and bladder movements-regular
Addictions-occasionally drinks alcohol
Allergies-none
FAMILY HISTORY:
There is no significant family history. None of his family members tested COVID-19 positive.
GENERAL EXAMINATION:
The patient was conscious, coherent and co - operative.
he is well oriented to time, place and person.
No pallor
No icterus
No clubbing
No cyanosis
No generalized lymphadenopathy
No bilateral pedal edema
VITALS:
pulse: 80bpm
blood pressure:110/70 mmhg
respiratory rate:22 cycles/min
spo2: 98% with room air
INVESTIGATIONS-
CBP-
Hb : 12.5 gm/dl
TLC : 4000 cells/cumm
DLC : Neutrophils - 78%
Lymphocytes - 20%
Eosinophils - 01%
Monocytes - 01%
Basophils - 00
Platelets : 2.42 lakhs /mm³
LFT
Total bilirubin : 0.87 mg/dl
Direct bilirubin : 0.20 mg/dl
SGOT : 24 units/ lit
SGPT : 18 units/ lit
ALP : 126 units/ lit
RFT
Blood urea : 52 mg/dl
Serum creatinine : 1.0 mg/dl
Calcium : 10.2 mg/dl
Phosphorus : 3.6 mg/dl
Sodium : 130 meq/lit
Potassium : 4.2 meq/lit
Chloride : 94 meq/lit
D- Dimer : 270 ng/ml
CRP : 2.4 mg/dl ( positive)
RBS : 103 mg /dl
ESR: 55 mm 1st hour
LFT
D-DIMER
CRP
RBS
CBP
RFT
HRCT CHEST on 16/05/
DIAGNOSIS:
pneumonia secondary to covid
TREATMENT:
O2 inhalation to maintain spo2 >90%
prone positioning
tablet PANTOP 40mg
tablet DEXAMETHASONE 4mg bd
tab DOLO 650mg sos
syp GRILLINCTUS 10ml tid
inj CLEXANE 40g bd
tablet AUGMENTIN 625mg bd
tablet MVT
tablet LIMCEE 800mg
Neb with DUOLIN at 6th hourly and Budecort at 8th hourly
monitor vitals 4th hourly
I would like to thank Dr.krishna durga , Dr. vamsi and Dr. vilasith for their guidance
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