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A 45 YR OLD MALE WITH COVID.

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 our 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-centred online learning portfolio and your valuable comments on comment box is welcome. 

 Name : Kattekola Sathwik 
 Roll no: 58 
 8th semester 

Following details were  provided to me by Intern Dr Anjali ma'am.

 Case details

A 45 year old male has presented with the casuality with the chief complaints of sudden onset shortness of breath on 2nd June 2021

History of presenting illness

The patient was apparently asymptomatic till June 2nd .
Then he developed grade 4 SOB which is of sudden onset.
There was a history of orthopnea
No history of fever, cough, cold, sore throat, loss of appetite, chest pain, palpitations, giddiness, sweating, blurring of visions, blackout

Based on the above history he was sent for rapid antigen test for covid-19 which he was tested positive on 2nd June 2021 and then he was admitted in COVID ICU 


History of past illness
No history of diabetes hypertension tuberculosis or epilepsy

Personal history 
Appetite : normal
Diet : mixed
Bowel and bladder habits: regular
Sleep : adequate
Addictions: No addictions

No history of drug and food allergies

Family history: not significant

General examination 
The patient is conscious for rent in cooperative
He is well oriented to time place and person
Moderately built and moderately nourished

Pallor: absent
Icterus:absent
Cyanosis:abent
Clubbing:absent
Lymphadenopathy: absent
Edema: absent 

Vitals
Temperature: afebrle
Pulse:  132bpm
Respiratory rate:33cpm
Blood pressure: 90/60 mmHg
SPO2:91 on room air
GRBS:100mg%


Systemic examination:

Cardiovascular system: s1 s2 heard,  No thrills and murmurs
Respiratory system;
  • DYSPNEA ; PRESENT
  • BILATERAL CREPTS 
Abdomen: SOFT and NON TENDER

CNS: NAD


Provisional diagnosis: VIRAL PNEUMONIA SECONDARY TO COVID -19 


Investigations

HEMOGRAM:   INCREASE IN NEUTROPHILS.
ESR : ELEVATED


RFT: ELEVATED UREA 

D DIMER 

LFT: ELEVATED ALP 




HRCT THORAX 





TREATMENT :

ON 2ND JUNE 2021

  1. NEB. BUDECORT+DUOLIN 8TH HOURLY
  2. TAB. PARACETAMOL500mg PO/SOS
  3. TAB.PANTOP 40mg PO/OD
  4. TAB.LIMCEE OD
  5. TAB.ZINCOVIT OD
  6. O2 SUPPLEMENTATION @10L/MIN  MAINTAINING AT SPO2 92%
  7. CONTINUOUS MONITORING OF BP ,SPO2 AND GRBS
ON 3RD JUNE 2021 
  1. O2 SUPPLEMENTATION TO MAINTAIN SPO2 >92%
  2. TAB.PCM 650MG PO SOS
  3. TAB PANTOP 40 MG PO OD\TAB. LIMCEE PO OD
  4. TAB MVT PO OD 
  5. NEB. WITH DUOLIN +BUDECORT  8TH HOURLY
  6. TAB. AUGMENTIN  625MG /PO/BD
  7. CONTINUOUS MONITORING
ON 4TH JUNE 2021
  1. O2 SUPPLEMENTATION
  2. TAB AUGMENTIN 625MG BD
  3. TAB LIMCEE OD
  4. TAB ZINCOVIT OD
  5. TAB PANTOP 40 MG OD 
  6. TAB DOLO 650 MG BD
  7. NEBULIZATION WITH DUOLIN +BUDECORT 8TH HOURLY


I thank Dr Anjali ( intern) ma'am, Dr Vinay sir  for helping me to make this log and I thank  Dr Rakesh sir for this opportunity.

    



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