42 years female patient with viral pneumonia secondary to covid-19

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N.Deepa, 8th semester
Roll no. 93

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 13/5/21) 

Case: 
       A 42 year old female patient came to the opd with chief complaints of fever since 10 days , dyspnea since 3 days, cough since 2 days and chest pain since 2 days. 

HISTORY OF PRESENT ILLNESS : 
       
           The patient was apparently asymptomatic 10 days back. Then she developed fever which was insidious in onset. It was a high grade intermittent type of fever without chills or rigors. She went to Rmp and he gave medication diagnosing her with typhoid and malaria. But fever didn't subside with those medications.Later she developed dyspnea on exertion 3 days back. She developed cough since 2 days which is a productive cough. Later she developed chest pain since 2 days. It is seen on exertion. She went to hospital 1 where she gave rapid antigen test which came out to be negative. But on doing CT her CT score was 16/25. So she was referred to higher centres by that doctor. So got admitted in our hospital on 13th of may and covid rapid antigen test done in the opd came out positive. 

PAST HISTORY :
  
   Medical history -   She is a known case of hypothyroidism since 4 years and she is on      Tab. Thyronorm 100mcg.
There is no history of  hypertension and asthma. 

   Surgical history - Hysterectomy 20 years back

PERSONAL HISTORY :

     Diet - Mixed

     Appetite - Decreased

     Sleep - Inadequate

     Bowel and Bladder movements - Regular

     Addictions - occasional toddy drinker

     Allergies - None

FAMILY HISTORY : 

There is no significant family history. None of her family members tested covid positive. 

GENERAL EXAMINATION :

The patient was conscious, coherent and co - operative. 

She is well oriented to time, place and person.

No pallor

No icterus

No clubbing

No cyanosis

No generalized lymphadenopathy

No bilateral pedal edema


VITALS : 

Temperature : Febrile

Pulse : 124 bpm

Blood pressure : 120/ 80 mm hg

Respiratory rate : 24 cycles / min

Spo2 : 82% on room air

SYSTEMIC EXAMINATION :

Cvs : S1 S2 heart sounds heard, No murmurs

Respiratory system : Bilateral air entry present. 

Cns : Intact

Abdomen : Soft and non - tender. Bowel sounds are heard. No organomegaly. 


INVESTIGATIONS :


CBP 
       Hb    : 12.7 gm%
       TLC  :  5700
       DLC  :  Neutrophils - 80
                    Lymphocytes - 15
                    Eosinophils - 02
                    Monocytes - 03
                    Basophils - 00
       Platelets : 1.5 lakhs /mm³

LFT 
        Total bilirubin : 1.24 mg/dl
         Direct bilirubin : 0.67 mg/dl
         SGOT : 73 units/ lit
         SGPT : 80 units/ lit
         ALP : 342 units/ lit

RFT 
         Blood urea : 34 mg/dl
         Serum creatinine : 0.4 mg/dl
         Calcium : 9.6 mg/dl
         Phosphorus : 4.4 mg/dl
         Sodium : 150 meq/lit
         Potassium : 5.2 meq/lit
         Chloride : 106 meq/lit

D- Dimer : 10 ng/ml

Serum LDH : 571 units/lit

CRP : 2.4 mg/dl ( positive)

FBS : 332 mg /dl










DIAGNOSIS : 
       
               Pneumonia secondary to covid - 19

TREATMENT :

  On 13/5/21 ( 10th day of symptoms) 
      
         • O2 supplementation
         •Head end elevation
         • Inj. DEXAMETHASONE 8mg/IV/TID
         •Inj. PANTOP 40mg/IV/OD
         • Tab. PCM 650mg/PO/SOS
         • Tab. LIMCEE PO/OD
         • Plenty of oral fluids
         • Tab. THYRONORM 100mcg/OD 

On 14/5/21 ( 11th day of symptoms) 

           • O2 supplementation
           • Head end elevation
           • Duolin budecort nebulization
           • Inj. DEXAMETHASONE 8mg / IV/ OD
           • Inj. PANTOP 40 mg / IV / OD
           • Tab. THYRONORM 100 mcg OD
           • Tab. LIMCEE OD
           • Tab. Mvt OD
           • Tab. PCM PO/SOS
           • Plenty of oral fluids
           • Inj. HAI 

Spo2 92% with 15 litres of oxygen

On 15/5/21 ( 12th day of symptoms) 

          • Prone positioning
          • O2 inhalation
          • Duolin budecort nebulization
          • Inj. DEXAMETHASONE 8mg IV OD
          • Inj. PANTOP 40 mg IV OD
          • Tab. THYRONORM 100 mcg OD
          • Tab. LIMCEE OD
          • Tab. Mvt OD
          • Tab. PCM SOS

Spo2 82% with 15 litres of oxygen


On 16/5/21 ( 13th day of symptoms) 

             •Prone positioning
             •O2 inhalation
             •Duolin budecort nebulization 
             •Inj. DEXAMETHASONE 8mg IV OD
             •Inj.PANTOP 40mg iv od
             •Tab. THYRONORM 100mcg
             •Tab. LIMCEE OD
             •Tab. Mvt OD
             •Tab. PCM SOS

Spo2 90% with 12 litres of oxygen


On 17/05/21 ( 14th day of symptoms) 

               •Prone positioning
               •O2 inhalation
               •Duolin budecort nebulization 
               •Inj. DEXAMETHASONE 8mg IV OD
               •Inj.PANTOP 40mg IV OD
               •Tab. THYRONORM 100mcg
               •Tab. LIMCEE OD
               •Tab. Mvt OD
               •Tab. PCM SOS

Spo2 90% with 10 litres of oxygen


On 18/05/21  ( 15th day of symptoms) 

               •Prone positioning
               •O2 inhalation
               •Intermittent Bipap
               •Duolin budecort nebulization 
               •Inj. DEXAMETHASONE 8mg IV OD
               •Inj.PANTOP 40mg IV OD
               •Tab. THYRONORM 100mcg
               •Tab. LIMCEE OD
               •Tab. Mvt OD
               •Tab. PCM SOS

Spo2 85% with 15 litres of oxygen


On 19/5/21  ( 16th day of symptoms  ) 

               • Prone positioning
               •O2 inhalation
               •Bipap
               •Duolin budecort nebulization 
               •Inj. DEXAMETHASONE 8mg IV OD
               •Inj.PANTOP  40mg IV OD
               •Tab. THYRONORM 100mcg
               •Tab. LIMCEE OD
               •Tab. Mvt OD
               •Tab. PCM SOS

Spo2 92% with Bipap


On 20/5/21  (  17th day of symptoms  ) 

               •Prone positioning
               •O2 inhalation
               •Intermittent Bipap ventilation 
               •Duolin budecort nebulization 
               •Inj. DEXAMETHASONE 8mg IV OD
               •Inj. CLEXANE 60 mg / sc / OD
               •Inj. PANTOP 40mg IV OD
               •Tab. THYRONORM  100 mcg
               •Tab. LIMCEE OD
               •Tab. Mvt OD
               •Tab. PCM SOS

Spo2 75% with room air
Spo2 90% with 15 litres of oxygen







    
On 21/05/21 ( 18th day of symptoms )

Fresh complaint of 1 fever spike today 

Treatment 
              •Prone positioning
              •O2 inhalation 
              • With Intermittent BIPAP
              •Duolin budecort nebulization 
              •Inj. DEXAMETHASONE 8mg IV OD
              •Tab.LEVOFLOXACIN 750mg /OD
              •Inj. PANTOP 40mg IV OD
              •Inj.CLEXANE 60mg/sc /OD
              •Tab. THYRONORM 100mcg
              •Tab. LIMCEE OD
              •Tab. Mvt OD
              •Tab. PCM SOS


Spo2 80% with room air
Spo2 95% with Bipap
Fio2  80%


On 22/5/21  ( 19th day of symptoms ) 
 
              •Prone positioning
              •O2 inhalation 
              •With Intermittent BIPAP
              •Duolin budecort nebulization 
              •Inj. DEXAMETHASONE 8mg IV OD
              •Tab. LEVOFLOXACIN 750mg /OD
              •Inj. PANTOP 40mg IV OD
              •Inj.CLEXANE 60mg/sc /OD
              •Tab. THYRONORM 100mcg
              •Tab. LIMCEE OD
              •Tab. Mvt OD
              •Tab. PCM SOS


Spo2 80% at room air
Spo2 91% with Bipap
Fio2  90% 





           


On 24/5/21 ( 21st day of symptoms  ) 

   No fever spike      
           
              •Prone positioning
               •O2 inhalation with face mask
               •Duolin budecort nebulization 
               •Inj. DEXAMETHASONE 8mg IV OD
               •Tab.levofloxacin 750mg /OD
               •Inj.PANTOP 40mg IV OD
               •Inj.CLEXANE 60mg/sc /OD
               •Tab.THYRONORM  100 mcg
               •Tab. LIMCEE OD
               •Tab. Mvt OD
               •Tab. PCM SOS

Spo2 91-93% with 15 litres of oxygen





   
              

            



                


                

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