70 year old male with cough, fever and shortness of breath
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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.
K.S.SASIRA
MBBS 8 SEM
ROLL NO. : 166
Following is my view of the case based on history as per date of admission :
Case :
A 70 year old male came to the opd on 15th may with the chief complaints of -
1)Dry cough since 10 days
2)fever since 10 days
3)shortness of breath since 4 days
History of presenting illness :
Patient was apparently assymptomatic 10 days back when he developed
- Dry cough which was insidious in onset , intermittent in nature with no diurnal or positional variations and no aggravating or relieving factors were noted.
- fever which was insidious in onset , intermittent in nature not assocoated with chills and rigors, was relieved on medication.
- later he developed shortness of breath 4 days back ,insidious in onset and gradual in progression with no complaints of vomitings , chest pain , loss of taste and smell.
He tested positive on RTPCR COVID with CT score of 10/25 following which he was admitted to COVID ICU
Past history:
■Not a k/c/o HTN ,DM,CAD,asthma,Tb
■Non alcholic, non smoker
Personal history:
■Diet - vegetarian
■Appetite - normal
■Sleep - adequate
■Bowel and bladder movements -regular
■Addictions-none
■Allergies-none
Family history :
■There is no significant family history
General examination:
Informed consent was taken before examining the patient and the examination was done in a well lit and ventilated room. Patient is moderately built and nourished .
■pallor:absent
■Icterus:absent
■Cyanosis:absent
■Clubbing:absent
■Lymphadenopathy:absent
■Edema:absent
■Dehydration : mild
●Vitals-
■On the day of admission(15/05/2021):
▪︎Pulse rate - 82bpm
▪︎Blood pressure- 110/60mm Hg
▪︎Afebrile
▪︎Respiratory-22/min
▪︎Spo2-86% on room air
93% with 10 lit of O2
■16/05/2021:
▪︎Pulse rate - 99bpm
▪︎Blood pressure- 120/90mm Hg
▪︎Afebrile
▪︎Spo2- 92% with 10 lit of O2
■17/05/2021:
▪︎Pulse rate - 98bpm
▪︎Blood pressure- 120/80mm Hg
▪︎Afebrile
▪︎Spo2- 96% with 4 lit of O2
■18/05/2021:
▪︎Pulse rate - 86bpm
▪︎Blood pressure- 110/70mm Hg
▪︎Afebrile
▪︎Spo2-95% with 6 lit of O2
■19/05/2021:
▪︎Pulse rate - 84bpm
▪︎Blood pressure- 110/70mm Hg
▪︎Afebrile
▪︎Spo2- 95% with 4 lit of O2
■20/05/2021:
▪︎Pulse rate - 70bpm
▪︎Blood pressure- 110/70mm Hg
▪︎ Afebrile
▪︎Spo2-93% on room air
96% with 2 lit of O2
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:
1) GRBS -401mg/dl on 16/05/2021
2)chest X-ray:
16/05/2021
17/05/2021
4)
17/05/2021
Provisional diagnosis:
Viral pneumonia secondary to Covid 19 and denovo Diabetes mellitus
Treatment:
■15/05/2021
• prone positioning
•O2 inhalation
•Inj.Dexamethasone-6mg/IV/OD
•Nebulisation with Duolin, budecort and mucomist-8th hourly
•Syp.Grillinctus-10ml/PO/TID
•T.PANTOP 40mg/PO/OD
•T.LIMCEE-OD
•T.PCM -650mg/PO/SOS
•IVF-NS with optineuron @ 75ml/hr continous
■16/05/2021:
•O2 inhalation
•Inj.Dexamethasone-6mg/IV/OD
•Nebulisation with Duolin, budecort and mucomist-8th hourly
•Syp.Grillinctus-10ml/PO/TID
•T.PANTOP 40mg/PO/OD
•T.LIMCEE-OD
•T.PCM -650mg/PO/SOS
•IVF-NS with optineuron @ 75ml/hr continous
•GRBS charting 6hourly
•Inj.HAI/SI/AS per slides
•Incentive spirometry
■17/05/2021:
•O2 inhalation
•Inj.Dexamethasone-6mg/IV/OD
•Nebulisation with Duolin, budecort and mucomist-8th hourly
•Inj.Clexane 60mg/SI/BD
•Syp.Grillinctus-10ml/PO/TID
•T.PANTOP 40mg/PO/OD
•T.LIMCEE-OD
•T.PCM -650mg/PO/SOS
•IVF-NS with optineuron @ 75ml/hr continous
•GRBS charting 6hourly
•Inj.HAI/SI/AS per sliding scale
•Incentive spirometry
■18/05/2021:
•O2 inhalation
•Inj.Dexamethasone-6mg/IV/OD
•Nebulisation with Duolin, budecort and mucomist-8th hourly
•Inj.Clexane 60mg/SI/BD
•Syp.Grillinctus-10ml/PO/TID
•T.PANTOP 40mg/PO/OD
•T.LIMCEE-OD
•T.PCM -650mg/PO/SOS
•IVF-NS with optineuron @ 75ml/hr continous
•GRBS charting 6hourly
•Inj.HAI/SI/AS per sliding scale
•Incentive spirometry
■19/05/2021:
•O2 inhalation
•Nebulisation with Duolin, budecort and mucomist-8th hourly
•Inj.Clexane 60mg/SI/BD
•Syp.Grillinctus-10ml/PO/TID
•T.PANTOP 40mg/PO/OD
•T.LIMCEE-OD
•T.PCM -650mg/PO/SOS
•IVF-NS with optineuron @ 75ml/hr continous
•GRBS charting 6hourly
•Inj.HAI/SI/AS per sliding scale
•Incentive spirometry
■20/05/2021:
•O2 inhalation
•IVF-NS with optineuron @ 75ml/hr continous
•Inj.Clexane 60mg/SI/BD
•GRBS charting 6hourly
•Inj.HAI/SI/AS per sliding scale
•Inj.Dexamethasone-6mg/IV/OD
•Syp.Grillinctus-10ml/PO/TID
•T.PANTOP 40mg/PO/OD
•T.LIMCEE-OD
•T.PCM -650mg/PO/SOS
•T.Mut/OD
•Incentive spirometry
Later that day the patient was discharged and was adviced to take medications as follows-
•O2 inhalation to maintain Spo2 >90%/SOS
•Tab.PAN 40mg/PO/1-0-0 × 1 week
•T.LIMCEE-PO/0-1-0 × 1 week
•Tab MVT/PO/0-1-0×1week
•Tab. DOLO 650mg/PO/SOS
•Syp.Grillinctus LS/PO/10ml/1-1-1×1week
•Incentive spirometry
Questions:-
1)what could be the long term complications of left lobe consolidation in this patient?
2)Did the covid 19 trigger new onset diabetes in this patient or was he an undiagnosed diabetic?
Under the guidance of Dr.charan sir
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