A 37 YEAR OLD FEMALE WITH FEVER, HEADACHE, BODY PAINS, SHORTNESS OF BREATH AND DRY COUGH
N. SAIKRISHNA
MBBS 8th semester
Roll no:101
This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .
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.
Following is the view of my case...
CASE:
A 37 year old female came to the OPD on 28th of May with chief complaints of
- FEVER since 7days
- HEADACHE since 7days
- BODY PAINS since 7days
- DRY COUGH since 2days
- DIFFICULTY IN BREATHING since 2 days
HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 7 days back when she developed
-Fever which was insidious in onset, intermittent in nature, not associated with chills and rigors and which was relieved on taking antipyretic.
- Headache which was more of right sided headache, which was sudden in onset, intermittent in nature, relieved on taking analgesics.
-Body pains which are relieved on taking analgesics
- Dry cough which was sudden in onset, intermittent in nature, with no diurnal or positional variations. No aggravating or relieving factors were noted.
-She developed Grade 2 shortness of breath(NYHA CLASSIFICATION) a day ago, insidious in onset and gradual in progression.
No complaints of vomitings, chest pain, loss of smell and taste.
PAST HISTORY:
« She is not a know case of Diabetes, Hypertension, Tuberculosis, Asthma, Thyroid.
« She has undergone septoplasty 1year back for Deviated nasal septum (DNS)
PERSONAL HISTORY:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel movements : Regular
Bladder movements : Burning sensation since 7days
Addictions: none
DRUG HISTORY:
Inj. MONOCF 4doses taken for typhoid at other hospital. 4days back
FAMILY HISTORY:
No history of similar complaints in the family.
No history of Diabetes, Tuberculosis, Stroke, Asthma, any other hereditary diseases in the family.
GENERAL EXAMINATION:
The patient is examined in a well lit room, with informed consent
The patient is conscious, coherent, cooperative, is well oriented to time, place, person.
She is moderately built and nourished.
Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent
VITALS:
On the day of admission-28/05/2021
Temperature-99°F
Heart rate-100 beats/min
Blood pressure-130/80 mmHg
Respiratory rate-18 cycles/min
SPO2-85% at room air
29/05/2021
Temperature-99°F
Heart rate-100 beats/min
Blood pressure-120/80 mmHg
Respiratory rate-19 cycles/min
SPO2-93%with 10litres of O2
SYSTEMIC EXAMINATION:
CVS: S1 and S2 heard
No added thrills, murmurs
RESPIRATORYSYSTEM:
Normal vesicular breath sounds heard
PER ABDOMEN: soft, non tender, no organomegaly
CNS: intact
INVESTIGATIONS:
COMPLETE BLOOD PICTURE
Hemoglobin-12.4gm/dl
Total count-7600cells/cu mm
Neutrophils-86%
Lymphocytes-10%
Monocytes-2%
Eosinophils-2%
Basophils-0%
Platelet count-1.30 lakh/cu mm
Smear- Normocytic normochromic with Neutrophilia and thrombocytopenia
Complete urine examination
LIVER FUNCTION TEST
Total Bilirubin-0.51mg/dl
Direct Bilirubin-0.20mg/dl
SGOT(AST)-37 IU/L
SGPT(ALT)-23 IU/L
Alkaline phosphatase-183 IU/L
Total proteins-5.4gm/dl
Albumin-2.9 gm/dl
A/G ratio-1.22
RENAL FUNCTION TEST
Urea-33mg/dl
Creatinine-0.9mg/dl
Uric acid-4.7mg/dl
Calcium-9.4mg/dl
Phosphorous-3.5mg/dl
Sodium-133mEq/L
Potassium-4.2mEq/L
C - reactive protein
Erythrocyte sedimentation rate
Glycated Hemoglobin
LDH levels
D-dimer levels
ECG REPORTS
Viral pneumonia secondary to COVID-19 INFECTION.
TREATMENT REGIMEN:
During the stay in the hospital
1. Head end elevation
2. O2 inhalation to maintain SPO2>90%
3.Intermittent BIPAP
4.IVF -20NS @ 75ml/hr with 1amp OPTINEURON
5.Inj. Dexamethasone 8mg/IV/OD
6.Tab PANTOP 40mg/IV/OD
7. Tab. DOLO 650mg/PO/OD
8.Tab.LIMCEE PO/OD
9. Monitor vitals
10.GRBS charting 8th hourly
11. Nebulization with DUOLIN and BUDECORT 6th hourly
12.Syp. AMBROXYL 10ml/PO/TID
With 1 glass of water
13.Advise plenty of oral fluids.
Under the guidance of Manasa madam
