A CASE OF 33 YEARS OLD FEMALE WITH SOB AND COUGH

  This is an 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 series of inputs from an 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-logbook also reflects my patient-centered online portfolio and your valuable inputs in the comments are welcome.

I would like to thank Dr. Chitra mam (Intern) for providing me all the information related to the below case.

 This is a case of 33 years old female who came to the hospital on 22/5/21 with :

CHIEF COMPLAINTS:

1) Shortness of breath since 1 day

2) Cough since 1 day

HISTORY OF PRESENT ILLNESS :

The patient was apparently asymptomatic 1 day back then she developed dyspnea at rest and productive cough with scanty mucoid sputum and no other associated symptoms.

She tested to be RAT positive on 22/5/21.

She is a 33 years old  G2P1L1 with 4 months of amenorrhea.

PAST HISTORY:

A K/C/O Hypothyroidism since 4 months and been on TAB.THYRONORM 12.5mcg since then.

Not a K/C/O diabetes mellitus, hypertension, TB, asthma.

PERSONAL HISTORY :

Diet: Mixed

Appetite: Normal

Sleep: adequate

Bowel and bladder movements: Regular

Addictions: No addictions

No known allergies

GENERAL EXAMINATION:

The patient was examined in a well lit room with informed consent.

Patient was conscious, coherent and cooperative, well oriented to time, place and person. 

  • Pallor : Absent
  • Icterus: Absent
  • Cyanosis: Absent
  • Clubbing: Absent
  • Lymphadenopathy : Absent
  • Edema : Absent

VITALS :

At the time of admission :

  • Temperature : Afebrile
  • BP: 100/80 mm/Hg
  • PR: 120 bpm
  • RR: 50 cpm
  • GRBS: 106

23/5/21, 8:00 am

  • Temperature : Afebrile       
  • BP -120/80mmhg 
  • PR- 103 /min
  • RR- 26/min
  • Spo2- 98% on 4 litres O2 facemask 
  • GRBS- 94 mg/dl

SYSTEMIC EXAMINATION :

CVS : S1 and S2 heard

RS : Basal crepts +

PER ABDOMEN : Perceiving fetal movements

CNS: Intact

LAB INVESTIGATIONS :

APTT - 32 sec

D-DIMER - 510 ng/ml

LDH- 316 IU/L

PT- 16 sec

INR- 1.1

DIAGNOSIS :

Moderate viral pneumonia secondary to COVID-19, G2P1L1 with hypothyroidism.

TREATMENT:

      22/5/21

  • O2 supplementation to maintain SpO2 > 92%
  • Intermittent BiPAP if needed
  • INJ.CLEXANE 40mg SC OD
  • IVF NS @ 75 ml/hr with 1 Ampule OPTINEURON
  • TAB.DOLO 650 mg/PO/SOS
  • TAB.LIMCEE PO/OD
  • TAB.THYRONORM 12.5 mcg PO/OD
  • GRBS charting 8th hourly
  • Monitor BP, SPO2,PR,RR
  • Plenty of oral fluids

      23/5/21, 8:00 am

  • O2 supplementation to maintain SpO2 > 92%
  • Intermittent BiPAP if needed
  • INJ.CLEXANE 40mg SC OD
  • IVF NS @ 75 ml/hr
  • TAB.DOLO 650 mg/PO/TID
  • TAB.LIMCEE PO/OD
  • TAB.THYRONORM 12.5 mcg PO/OD
  • Nebulization with DUOLIN 8th hourly , BUDECORT 12th hourly
  • GRBS charting 8th hourly
  • Monitor BP, SPO2,PR,RR
  • INJ.DEXAMETHASONE 6mg/IV/OD x 10 days
  • INJ.REMEDESIVIR 200mg/IV/STAT
               

The patient attenders took the patient on LAMA due to financial constraints. The patient got discharged on 23/5/21.

Comments

Post a Comment

Popular posts from this blog

ONLINE BLENDED BIMONTHLY ASSIGNMENT

Image
 Name: C.SAI SPOORTHY Roll no : 115 8th SEMESTER    I have been given the following cases 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 diagnosis and come up with a treatment plan. This is the link to the assignment : http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1   Below are my answers to the assignment based on my understanding and clinical knowledge of the cases. 1) PULMONOLOGY  : A) Link to patient details : https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html 1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? A. Evolution of Symptomatology : 20 Years ago - SOB Grade 1
Read more

FINAL PRACTICAL LONG CASE : Case of a 70 year old male with recurrent CVA

Image
GENERAL MEDICINE - FINAL PRACTICAL EXAM LONG CASE Hallticket no: 1701006158 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. CASE PRESENTATION: This is a case of a 70 year old male who was cattle grazer by occupation came to the casuality with:  CHIEF COMPLAINTS: Weakness in the right sided upper limbs and lower limbs since 3 days Slurring of speech since 3 days HISTORY OF PRESENTING ILLNESS : Patient was apparently asymptomatic 5 years back, then he had experienced weakness in right upper and lower limbs. It was sudden in onset not associated with slurring of speech or drooling of saliva. Patient complained that he suddenly couldn't move his right upper and lower limbs while walking up the stairs. Then he was treated conservatively and weak
Read more