A CASE OF 70 YEARS OLD MALE WITH COUGH AND SOB

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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 70 years old male who came to the hospital on 22/5/21 with :

CHIEF COMPLAINTS:

1) Cough since 5 days

2) Shortness of breath since 5 days

HISTORY OF PRESENT ILLNESS :

The patient was apparently asymptomatic 5 days back then he developed productive cough and shortness of breath ( Grade IV ) associated with generalised body pains.

No H/O fever, loss of smell and taste

No H/O pedal edema, palpitations, abdominal distension.

PAST HISTORY:

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

PERSONAL HISTORY :

Diet: Mixed

Appetite: Normal

Sleep: adequate

Bowel and bladder movements: Regular

Addictions: Patient is a chronic smoker

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: 80/50 mm/Hg
  • PR: 80 bpm
  • RR: 35 cpm
  • SpO2: 84% on RA
  • GRBS: 131 mg/dl
22/5/21, 6:40 pm
  • Temperature : Afebrile
  • BP: 100/60 mm/Hg
  • PR: 120 bpm
  • RR: 38 cpm
  • SpO2: 95% on 15 lit of O2

23/5/21, 8:00 am

  • Temperature : Afebrile       
  • BP -110/70mmhg 
  • PR- 71 /min
  • RR- 32/min
  • Spo2- 92% on RA
  • GRBS- 94 mg/dl

SYSTEMIC EXAMINATION :

CVS : S1 and S2 heard

RS : NVBS

PER ABDOMEN : soft, non-tender

CNS:  Intact

LAB INVESTIGATIONS :

Hemogram:

  • Hb: 13.9
  • TLC: 14,700
  • Plt: 3.73

ABG:

  • pH - 7.327
  • pCO2- 21
  • SpO2- 87.9%
  • st HCO3- 140

LFT:

  • TB-1.18
  • DB- 0.34
  • AST- 32
  • ALT- 52
  • ALP- 408
  • TP-5.9
  • Alb- 2.5
  • A/G- 0.75

CRP : +ve

D-DIMER - 2610 ng/ml

Sr.LDH- 551 IU/L

HbA1C-6.7%

RTPCR for COVID-19: negative

DIAGNOSIS 

Severe viral pneumonia secondary to COVID-19.

TREATMENT:

      22/5/21

  • IVF NS, RL @ 100 ml/hr
  • INJ.DEXAMETHASONE 8mg/IV/OD
  • INJ.CEFTRIAXONE 1 gm IV/BD
  • INJ.LEVOFLOXACIN 750 mg IV/BD
  • INJ.CLEXANE 40mg/OD
  • INJ.OPTINEURON 1 amp in 10 NS /IV/OD
  • INJ.PAN 40mg /IV/BD
  • TAB.DOLO 650 mg/SOS
  • TAB.LIMCEE PO/OD
  • TAB.MONTEK LC 10/5 mg PO/HS
  • SYP.ASCORYL 10mg/PO/TID
  • AWAKE PRONING
  • O2 INHALATION WITH FACE MASK
  • Nebulization with DUONASE AND MUCOMIST 8th hourly , BUDECORT 12th hourly
  • HEAD END ELEVATION
  • PLENTY OF ORAL FLUIDS
  • I/O CHARTING
  • Monitor BP, SPO2,PR, TEMP.

      23/5/21, 8:00 am

  • IVF NS, RL @ 100 ml/hr
  • INJ.DEXAMETHASONE 8mg/IV/OD
  • INJ.CEFTRIAXONE 1 gm IV/BD
  • INJ.LEVOFLOXACIN 750 mg IV/BD
  • INJ.CLEXANE 40mg/OD
  • INJ.PAN 40mg /IV/BD
  • TEMP MONITORING
  • TAB.DOLO 650 mg/SOS
  • TAB.LIMCEE PO/OD
  • TAB.MONTEK LC 10/5 mg PO/HS
  • SYP.ASCORYL 10mg/PO/TID
  • AWAKE PRONING
  • O2 INHALATION WITH FACE MASK
  • Nebulization with DUONASE AND MUCOMIST 8th hourly , BUDECORT 12th hourly
  • HEAD END ELEVATION
  • I/O CHARTING
  • Monitor BP, SPO2,PR.
               

The patient attenders want to take the patient to another centre due to financial constraints against medical advise. The patient got discharged on 23/5/21.

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