A 70 YEAR OLD MALE WITH VIRAL PNEUMONIA SECONDARY TO COVID-19 WITH k/c/o DM, HTN, PSORIASIS.

 A 70 YEAR OLD MALE WITH VIRAL PNEUMONIA SECONDARY TO COVID-19,WITH k/c/o DM, HTN, PSORIASIS. 

May 27,2021

This is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 centered online learning protfolio and your valuable inputs on comment box is welcome.

Navya Rathlavath

Roll No:112,8th Sem

May 27,2021.

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 comeup with Diagnosis and Treatment plan.

Following is the view of my case:(Under the guidance of Dr.Saicharan Sir,P.G) 

CASE DISCUSSION:

Date of Admission:18/05/2021,11;24 AM

A 70 year old male presented to the opd on 18/05/2021 with 

CHIEF COMPLAINTS of:-

*FEVER since 14 days and got resolved

*SOB since 7 days

*COUGH since 7 days

*GENERALIZED BODY PAINS since 7 days

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 14 days back and then he developed,

FEVER which was insidious in onset,intermittent in nature,on and off ans not associated with chills and rigor and relieved on medication.

SOB since 7 days,which is grade-2,no h/o orthopnea and did not take any oxygen inhalation.

COUGH since 7 days which was insidious in onset,non productive,no aggravating and relieving factors.

GENERALIZED BODY PAINS since 7 days.

Loss of Appetite.

No H/o loss of taste or smell. 

No H/o headache. 

PAST HISTORY:-

*known case of DIABETES MELLITUS since 15 years and on OHA's

*known case of HTN since 20years and on Anti-Hypertensives

*Past H/O CABG(Coronary Artery Bypass Grafting) done 3 years back 

*known case of PSORIASIS 15 years back 

-No similar complaints in the past.

-Not a known case of Asthma,T.B,Epilepsy.

PERSONAL HISTORY:-

• Diet-mixed
• Appetite-decreased
• Sleep-adequate
• Bowels-regular
• micturition-normal
• Addictions-None
• Allergies-None

FAMILY HISTORY:

 Family history is not significant. 

GENERAL EXAMINATION:-

The patient was conscious,coherent and cooperative.

He is well oriented to time,place and person.

He is moderately built and moderately nourished.

No PALLOR

No ICTERUS

No CYANOSIS

No CLUBBING

No GENERALIZED LYMPHADENOPATHY

No PEDAL OEDEMA

VITALS:-

18/05/2021

• temperature : afebrile
• pulse rate : 130bpm
• respiratiory rate : 32/min
• blood pressure : 110/70mmHg
• spo2 at room air : 87%

19/05/2021

• temperature : afebrile
• pulse rate : 110bpm
• blood pressure : 110/90mmHg
• spo2 : 95% at 4L of O2

20/05/2021

• temperature : afebrile
• pulse rate : 104bpm
• blood pressure : 110/70mmHg
• spo2 at room air : 92%
• spo2 : 96% at 10L of O2

21/05/2021

• temperature : afebrile
• pulse rate : 96bpm
• blood pressure : 110/70mmHg
• spo2 at room air : 92%
• spo2 : 98% at 2L of O2

22/05/2021

• temperature : afebrile
• pulse rate : 101bpm
• blood pressure : 120/70mmHg
• spo2 at room air : 77%
• spo2 : 98% at 10L of O2 NRM
• GRBS : 210mg/dl
• CT  severity score : 19/25

23/05/2021

• temperature : 99 degree F
• pulse rate : 115bpm
• respiratory rate : 22/min
• blood pressure : 120/80mmHg
• spo2 : 93% at 10L of O2 NRM
• GRBS : 152mg/dl

24/05/2021

• temperature : afebrile
• pulse rate : 124bpm
• respiratory rate : 24/min
• blood pressure : 130/80mmHg
• spo2 at room air : 69%
• spo2 : 91% at 12L of O2 NRM

25/05/2021

• temperature : afebrile
• pulse rate : 114bpm
• respiratory rate : 22/min
• blood pressure : 130/80mmHg
• spo2 : 90% at 10L of O2 NRM
• spo2 : 94% at 14L of O2 NRM

26/05/2021

• temperature : afebrile
• pulse rate : 103bpm
• respiratory rate : 22/min
• spo2 : 97% on NRM -10L of O2
• GRBS : 95mg/dl

27/05/2021

• temperature : afebrile 
• pulse rate : 130bpm,reg
• respiratory rate : BAE+, on NRBM
• SPO2 : 98% on NRBM at 15L of O2
• GRBS : 362mg/dl

28/05/2021 [ Day 24 of illness]

*temperature : afebrile

*pulse rate : 101bpm

*respiratory rate : 27/min

*SpO2 : 78% on Room Air

*SpO2 : 90% on BiPAP

*GRBS @8AM : 163 mg/dl

*CT severity score : 19/25 (17/5) 

 (CORADS-5) 

SOB has reduced comparatively. 

29/05/2021[Day 25 of illness]

*temperature : afebrile

*pulse rate : 96bpm

*blood pressure : 110/70mmHg

*SpO2 : 92% with with 15L of O2. 

*GRBS @ 8 AM : 171mg/dl

30/05/2021[Day 26 of illness]

*temperature : afebrile

*pulse rate : 99bpm

*Blood pressure : 110/70mmHg

*SpO2 : 97% @ high flow O2

*GRBS @ 8AM : 80 mg/dl

31/05/2021[Day 27 of illness]

*temperature : afebrile

*pulse rate : 96bpm

*Blood pressure : 110/70mmHg

*SpO2 : 92% with NRBM with 15L of O2

*GRBS @ 8AM : 80 mg/dl

01/06/2021[Day 28 of illness]

*temperature : afebrile

*pulse rate : 100bpm

*Blood pressure : 110/70mmHg

*SpO2 : 99% with NRBM with 15L of O2

*GRBS @ 7AM : 70 mg/dl

SYSTEMIC EXAMINATION:-

cvs-

S1 and S2 heart sounds heard

No murmurs heard

respiratory system-

Bilateral air entry- present

NVBS-present

cns-

intact

abdomen-

abdomen-scaphoid

soft and non tender

No organomegaly

-No pedal edema

-No jaundice

Clinical pictures:

PROVISIONAL DIAGNOSIS:-

viral pneumonia secondary to covid-19 with k/c/o DM, HTN, psoriasis.

INVESTIGATIONS ORDERED:-

CBP, LDH, ESR, CRP, D-dimer, RFT, LFT,

 ECG, LXR, FBS, PLBS, HbA1C, ABG.

-CBP:

18/05/2021

21/05/2021

-LDH:

18/05/2021

-ESR:

18/05/2021

-CRP:

18/05/2021

-D-dimer:

18/05/2021

19/05/2021

21/05/2021

-RFT:

18/05/2021

-LFT:

18/05/2021

-FBS:

18/05/2021

-ABG:

18/05/2021

-ECG: 

18/05/2021

19/05/2021

24/05/2021

-CT Chest and Abdomen:

TREATMENT REGIMENT:-

18/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.T.P.R . BP charting +SpO2

10.Inform SOS

11.GRBS checking 6th hourly(8AM-1PM-8PM-2AM) 

12.Tab.Glimepiride 1mg/po/OD(8AM-before breakfast) 

13.Tab.Metformin 500mg po/BD(9AM & 9PM) 

14.Tab.Telma AM 40/5/po/OD(8 AM) 

15.4 Egg whites/day

16.Inj CLEXANE 40 mg s/c BD

17.Inj.Dexamethasone 8mg/IV/OD

19/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.T.P.R . BP charting +SpO2

10.GRBS checking 6th hourly(8AM-1PM-8PM-2AM) 

11.Tab.Telma AM 40/5/po/OD(8 AM) 

12.Inj CLEXANE 40 mg s/c BD

13.Inj.Dexamethasone 8mg/IV/OD

14.Tab.Ecosprin-AV-180mg/po/OD

20/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Inj.Dexamethasone 8mg/IV/OD

12.Tab Ecosprin-AV-180mg/po/OD

21/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Inj.Dexamethasone 8mg/IV/OD

12.Tab Ecosprin-AV-180mg/po/OD

22/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Inj.Dexamethasone 8mg/IV/OD

12.Tab Ecosprin-AV-180mg/po/OD

23/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Inj.Dexamethasone 8mg/IV/OD

12.Tab Ecosprin-AV-180mg/po/OD

13.GRBS-70 profile monitoring

 (before breakfast, 2 hrs after breakfast, Before lunch, 2 hrs after lunch, before dinner, 2hrs after dinner) 

14.Tab.Glimepiride 1mg/BD

15.Inj.HAI s/c, sos TID

24/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Inj.Dexamethasone 8mg/IV/OD

12.Tab Ecosprin-AV-180mg/po/OD

13.GRBS-70 profile monitoring

14.Tab.Glimepiride 1mg/BD

15.Inj.HAI s/c, sos TID

25/05/2021 

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Tab Ecosprin-AV-180mg/po/OD

12.GRBS-70 profile monitoring

13.Tab.Glimepiride 1mg/BD

14.Inj.HAI s/c, on sliding scale(sos) 

15.Tab.Metformin 500mg/po/BD

16.Syp.Ascoryl 10ml QID

(Inj.Dexamethasone stopped) 

26/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Pan 40/po/OD

4.Tab.Dolo 650/po/sos

5.Tab.Limcee/po/OD

6.Tab.MVT/po/OD

7.Nebulisation:Duolin, budecort, mucomist-6th hourly.

8Tab.Telma 40/5mg/po/OD

9.Inj CLEXANE 40 mg s/c BD

10.Tab Ecosprin-AV-180mg/po/OD

11.GRBS-70 profile monitoring

12.Tab.Glimepiride 1mg/BD

13.Inj.HAI s/c, on sliding scale(sos)

14.Tab.Metformin 500mg/po/BD

15.Syp.Ascoryl 10ml QID

(Tab.Augmentin stopped) 

27/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Pan 40/po/OD

4.Tab.Dolo 650/po/sos

5.Tab.Limcee/po/OD

6.Tab.MVT/po/OD

7.Nebulisation:Duolin, budecort, mucomist-6th hourly

8.Tab.Telma 40/5mg/po/OD

9.Inj CLEXANE 40 mg s/c BD

10.Tab Ecosprin-AV-180mg/po/OD

11.GRBS-70 profile monitoring

12.Tab.Glimepiride 1mg/BD

13.Inj.HAI s/c, on sliding scale(sos) 

14.Tab.Metformin 500mg/po/BD

15.Syp.Ascoryl 10ml QID1

16.Intermittent BiPAP

28/05/2021[Day 24 of illness]

1.Continuous BiPAP

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Pan 40/po/OD

4.Tab.Dolo 650/po/sos

5.Tab.Limcee/po/OD

6.Tab.MVT/po/OD

7.Nebulisation:Duolin,mucomist-8th hourly;Budecort-12th hourly

8.Tab.Telma 40/5mg/po/OD

9.Inj CLEXANE 40 mg s/c BD

10.Tab Ecosprin-AV-180mg/po/OD

11.Tab.Glimepiride 2mg/po/BD

12.Metformin 500mg/po/BD

13.Inj.HAI s/c,on sliding scale (sos)TID

14.GRBS monitoring (70 profile) -6th hourly

15.Monitor vitals

16.Syp.Ascoryl 10ml QID

29/05/2021[Day 25 of illness]

1. Inj clexane 40mg SC bd (D11)

2. Intermittent BiPAP

3. Tab ecospirin Av-150/40 po/od  

4. tab metformin 500 mg po/od 

5. Tab pantop 40mg po od

6. Tab limcee 500mg po od 

7. Tab zincovit po od

8. tab glimeperide 2mg po/bd

9. Tab dolo 650mg po sos 

10. Nebulisation with budecort 8th hourly 

11. Syp ascoril 15ml po hs 

12. Grbs monitoring-6th hrly

13. Spirometry 

14. Prone positioning 

 15.Monitor vitals

30/05/2021[Day 26 of illness]

1. Inj clexane 40mg SC bd (D12) 

2. Intermittent BiPAP

3. Tab ecospirin Av-150/40 po/od  

4. tab metformin 500 mg po/od 

5. Tab pantop 40mg po od

6. Tab limcee 500mg po od 

7. Tab zincovit po od

8. tab glimeperide 2mg po/bd

9. Tab dolo 650mg po sos 

10.Tab.telma 40 mg po OD

11.Nebulisation with budecort 8th hourly 

12. Syp ascoril 15ml po hs 

13. Grbs monitoring-6th hrly

14.inj HAI s/c according to sliding scale 

15.Monitor vitals and inform sos

31/05/2021[ Day 27 of illness]

1. Inj clexane 40mg SC bd (D13) 

2. Intermittent BiPAP

3. Tab ecospirin Av-150/40 po/od  

4. tab metformin 500 mg po/od 

5. Tab pantop 40mg po od

6. Tab limcee 500mg po od 

7. Tab zincovit po od

8. tab glimeperide 2mg po/bd

9. Tab dolo 650mg po sos 

10.Tab.telma 40 mg po OD

11.Nebulisation with budecort 8th hourly 

12. Syp ascoril 15ml po hs 

13. Grbs monitoring-6th hrly

14.spirometry and prone positioning

15.Monitor vitals and inform sos

01/06/2021 [Day 28 of illness]

1. Inj clexane 40mg SC bd (D11)

2. Intermittent BiPAP

3. Tab ecospirin Av-150/40 po/od  

4. tab metformin 500 mg po/od 

5. Tab pantop 40mg po od

6. Tab limcee 500mg po od 

7. Tab zincovit po od

8. tab glimeperide 2mg po/bd

9. Tab dolo 650mg po sos 

10. Nebulisation with budecort 8th hourly 

11. Syp ascoril 15ml po hs 

12. Grbs monitoring-6th hrly

13. Spirometry 

14. Prone positioning 

 15.Monitor vitals

*Patient admitted to the hospital (on 18/05/2021) after 2 weeks of appearance of symptoms.

*Duration of Hospital stay-15days (not yet discharged) 

*Dependence on oxygen-15L of O2 (as on 31/05/2021) 

*Covid severity-Moderate. 

I would like to thank Dr.Rakesh Biswas sir(H.O.D,General Medicine) for giving me this oppurtunity and thankyou Dr.Sai Charan sir(P.G,General Medicine)for the guidance.