||CASE 1: 2021|| A 42YR OLD MALE WITH FEVER AND COUGH.

M. MEGHANA

ROLL NO:90

MEDICINE CASE REPORT:      PATIENT WITH FEVER AND COUGH 

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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 a diagnosis and treatment plan.

CHIEF COMPLAINTS:

A 42 YEAR OLD MALE PATIENT PRESENTED WITH A HISTORY OF 

1. FEVER SINCE 8 DAYS   AND

2. COUGH SINCE 8 DAYS .

HISTORY OF PRESENTING ILLNESS:

1.  ON THE DAY OF ADMISSION(19/05/2021):

  Patient was apparently asymptomatic 8 days back when he developed FEVER , which was sudden in onset, intermittent, high grade, not associated with chills and rigor, relieved on medication.

Then, he also developed COUGH,  which was productive, with scanty, non blood stained, mucoid, odourless sputum. No diurnal variation, No positional variation. No hemoptysis.

 - No complaints of  Shortness of breath (SOB), Orthopnoea, or PND.

 - No complaints of chest pain, pedal edema, decreased urine output, no loss of appetite.

2.  ON 20/05/2021:

Patient's FEVER has SUBSIDED and his oxygen saturation was 86% on room air.

Patient has developed SHORTNESS OF BREATH ( GRADE III -- MMRC ). Patient was prescribed O2 inhalation with intermittent BiPAP, and his saturations increased to 90% with 15L of O2. 

3.  ON 21/05/2021:

Patient is AFEBRILE.

Patient was subjectively feeling better.

Patient has SHORTNESS OF BREATH ( GRADE II -- MMRC). Patient was prescribed O2 inhalation with intermittent BiPAP, and his saturation improved to 95% with 10L of O2.

4.  ON 22/05/2021:

Patient is febrile, probable cause being IV infusion of fluids and steroids. It can be INFUSION THROMBOPHLEBITIS. 

Patient also developed hyperglycemia, which can be due to use of dexamethasone.

 

HISTORY OF PAST ILLNESS:

--Patient is a known  case of hypertension, since 5yrs.

--Patient has no history of Diabetes Mellitus, tuberculosis, coronary artery disease, epilepsy.

PERSONAL HISTORY:    

DIET: mixed

APPETITE: normal

SLEEP: adequate

BOWEL AND BLADDER: regular

ADDICTIONS: no known addictions

ALLERGIES: no allergies

DRUG HISTORY: 

Patient was on AMLONG 5mg for Hypertension.

FAMILY HISTORY: 

The patient's mother also tested positive for COVID-19. 

GENERAL EXAMINATION: Patient was conscious and coherent.

Pallor: absent

Icterus: absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

Edema: absent

VITALS:   

ON THE DAY OF ADMISSION ( 19/05/2021):

BP: 100/70 mm pf Hg

PR: 110bpm

RR: 30 cycles/ min

TEMP: febrile, 104°F

SpO2: 86% on Room air,     6L OF OXYGEN FOR 96%

ON 20/05/2021:

BP: 110/70 mm Hg

PR: 120 bpm

RR: 30 cycles/min

TEMP: afebrile

SpO2: 86% on room air,  90% with 15L of oxygen

ON 21/05/2021:

BP: 110/70 mm Hg

PR: 110/min 

RR: 26/min 

TEMP: Afebrile

SpO2: 90% on 10L of oxygen 

SYSTEMIC EXAMINATION: 

1. CVS: S1 and S2 heard

2. PA: No significant observations 

3.CNS: All senses are normal.

INVESTIGATIONS:  

ON THE DAY OF ADMISSION (19/05/2021):

                                                           COVID-19 RT-PCR REPORT

SERUM C- REACTIVE PROTEIN

                                                              SERUM LDH LEVEL

                                                          RENAL FUNCTION TEST REPORT

                                                            COMPLETE BLOOD PICTURE

                                                              LIVER FUNCTION TEST 

                                                              PLASMA  D-DIMER LEVELS

 

ON 20/05/2021:

                                                                         HEMOGRAM 

LIVER FUNCTION TEST

RENAL FUNCTION TEST

PLASMA D-DIMER 

GLYCATED HAEMOGLOBIN

SERUM   LDH  LEVELS

 

ON 21/05/2021:

CHEST  X--RAY :

PROVISIONAL DIAGNOSIS:    VIRAL PNEUMONIA SECONDARY TO COVID-19 INFECTION

TREATMENT:  

 1. On the day of admission ( 19/05/2021 ):

1.PROPPED UP POSTURE

2.OXYGEN INHALATION 6-8lit/day

3.FREQUENT PRONE POSITION

4.INJ. DEXA 8mg iv/OD 

5.INJ. CLEXANE 40mg SC OD 

6.T. PCM 650mg / PO/ TID 

7.Strict temperature charting 4th  hourly

8.SYP ASCORIL 

9.TAB AMLONG 5mg / OD

10. NEBULISATION BUDOCORT & DUOLIN 

11. TAB. LIMCEE PO/OD

12.TAB. ZINCOVIT PO/OD

2. TREATMENT ON 20/05/2021:

1. INTERMITTENT BIPAP

2. INJ. DEXA 8mg IV

3. INJ. CLEXANE 40mg SC

4. Tab. PCM 650mg/ PO/ QID

5. Tab. LIMCEE 

6. Tab. ZINCOVIT PO/OD

7. Tab. AMLONG 5mg/OD

3. TREATMENT ON 21/05/2021:

1. INTERMITTENT BIPAP

2. AWAKE PRONING

3. INJ. DEXA 8mg IV

4. INJ. CLEXANE 40mg SC

5. Tab. PCM 650mG /PO/QID

6. Tab. LIMCEE 

7. Tab. ZINCOVIT PO/OD

8. Tab. AMLONG 5mg/OD 

9. MAINTAIN HYDRATION