GENERAL MEDICINE CASE DISCUSSION

 A 38-YEAR-OLD MALE WITH VIRAL PNEUMONIA SECONDARY TO COVID 19

  June 6th, 2021

Y.NAVYA SAHITHI REDDY

ROLL NO.146

MBBS,8TH SEM

This is an online E Logbook 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 a series of inputs from an available global online community of experts 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 in the comment box are 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 a diagnosis and treatment plan.

following is the view of my case...

CASE PRESENTATION

 A 38-year-old male who is a cycle mechanic by  occupation presented to the OPD on 6/6/2021 with the

chief  complaints of 

• high-grade fever since 5 days
• generalized body pains since 4 days 
• chest pain since 4 days 

History of present illness:

                                   The patient was apparently asymptomatic 5 days back, Later he developed a fever of high grade not reliving with medication since 5 days, backache and joint pains since 4 days and he tested for SARS-COV-2 where the result turned out to be negative. Later, an investigation of chest pain got HRCT CHEST done which showed CORADS 5.

On 8/6/21 patient complained of severe headche, with left sided earache,facial pain and tooth ache. So patient was referred to the ent and dental department for opinion 

He had no nasal  obstruction, nasal discharge, nasal bleed and no anosmia 

No c/o of cough, hemoptysis, SOB 

History of past illness: 

• known case of diabetes mellitus type II
• no h/o previous hospitalization
• no HTN, Asthma, TB, CAD
• no history of any previous surgeries

 Treatment history :

               Tab METFORMIN -1000Mg/OD

                TAB GLIMEPERIDE-2Mg/OD   for DM TYPE II  for 1 year.

other medications; for covid 19, TAB FAVIPIRAVIR -1600Mg /stat dose taken.

Personal History:

         Married

        Appetite -normal

        sleep: adequate

        Diet; Mixed diet

        Bowel and bladder movements: regular

        micturition :normal

         no known allergies 

         addictions: regular gutka chewer  

Family History: No significant family history 

GENERAL EXAMINATION:

 The patient is conscious, coherent, cooperative, well-nourished, well -oriented to time, place, person,

     Pallor: no

     Icterus: no

     Cyanosis: no

     Lymphadenopathy: no

    Edema: no 

    Clubbing of fingers: no

VITALS at the time of admission: (4pm)

     Temperature: 100 F (febrile)

    Pulse rate: 99/min

On 8/6/21 PR: 48/min

     Respiration rate :33 cycles/min

      BP : 100/60 mm/hg 

     SPO2 at room air: 78% 

                                   92% on 15 lit of O2 

On 8/6/21 spo2 : 94% on 12 lit of O2

    GRBS: 262 mg%

SYSTEMIC EXAMINATION 

 CVS: S1 & S2 heard 

           no murmurs and cardiac thrills

RESPIRATORY SYSTEM:

         Dyspnoea: present

        Wheeze: absent

          no adventitious sounds heard 

ABDOMEN:

 Inspection

  the shape of the abdomen: scaphoid

 palpation;

   Tenderness- not present

    no palpable mass

   hernial orifices: normal

   liver and spleen not palpable

percussion :

liver span: normal

auscultation;

  bowel sounds: yes 

CNS: intact 

gait: normal 

ENT :

It was done on day 8 of illness.

External frame work-normal 

columella and vestibule -normal

septum -Centre

mucosa-normal

turbinates-normal

PNS -normal

oral cavity- normal

             teeth-nicotine stained

Oropharynx-normal.

DENTAL examination 

Malpositioned

 Lingual mucosa and patient has Tenderness on palpation 

tooth is tender on percussion 

Oral swelling at angle of mandible extending till zygomatic arch.

INVESTIGATIONS

HRCT -CHEST scan

CORADS -5

CT SCORE - 22/25

RFT :

uric acid : 3.3 mg/dl                  

                                                   

  LFT:

total bilirubin: 1.79 mg/dl

direct bilirubin: 0.33 mg/dl

SGOT;47 IU/L

SGPT : 54 IU/L

ALKALINE PHOSPHATE: 207 IU/L

TOTAL PROTEINS: 5.9 gm/dl

                                                   

    ABG: 

AFTAB ABG :9 PM

ph: 7.33

pco2: 40.4

po2: 39.3

saturation: 62.6%

bicarb :21.2

standard bicarb : 20.5

                                          

                               CBP;

                                    Hb-13.2%

                                     TLC-6900/mm3

                                     platelet count-1.71 lacs 

                            CRP +VE 

                            

                                  ECG:          

                                            

   

Provisional Diagnosis :

                       viral pneumonia secondary to COVID 19 and left lower tooth apical abscess and buccal space infection. 

Treatment history:

                on 6/6/21 (4pm) 

             1) O2 supplementation -15 lit/min maintain spo2>90%

             2) intermittent BiPap

             3)inj. dexamethasone -6mg i.v /od

             4) inj. clexane- 40mg s.c / od 

              5) tab Limcee -po/tid

               6) tab : zincovit PO/OD

              7) inj. HAI- S.C  ss after informing p.g ( 8 am -1pm-8pm)

              8) GRBS monitoring -8th hrly (8-1-8-2)

               9) tab dolo -650 mg PO/ tid

              10) tepid sponging /ice packs

              11) fever charting 4 hrly 

              12)monitor vitals

               13) inj.  Remedesivir -200mg i.v stat 

                                                        100mg i.v OD for 5 days                                        

                                   

under the guidance of Dr. Sufiya mam(3rd-year P.G), Dr.Avinash sir (intern),Dr.Pavan sir (intern).