29 year old male patient with viral pneumonia secondary to COVID-19

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MEDICINE CASE DISCUSSION


This is an 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 individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome

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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