This is online E log book 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 available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome .
In order to comprehend and analyse the severity of COVID this is a e-log of patient centred covid progression along with other newly discovered conditions such as Denovo diabetes.
This is my reflection of the case study:
45year old Female , resident of Nalgonda. Presented with the following complaints:
Fever since,6days
Cough since,6days
SOB since,2days.
Tested positive for covid-19 through rt-pcr on 29/05/2021. I.e 6days back.(ref. 4/06/2021).
History of presenting illness:
Patient was apparently asymptomatic 6 days back later developed,
Fever, high-grade, intermittent, since 6days
Cough,non productive, since,6days.
Shortness of breath , Mmrc grade 3-4, since 2days.
Got tested on the first day of symptoms for covid-19 and tested positive
Past history:
H/o Hypertension since 2years. On treatment
Denovo diabetes mellitus since 2days (HbA1c: 11.7) on treatment
No other history of trauma, or any chronic illness.
Personal history:
Married.
Appetite: normal., Non vegetarian- no exotic animal meat consumption.
Bowel movements and bladder behaviour normal.
No known allergies and addictions.
Family history:
No similar complaints in the family.
General physical examination:
Patinet is well built and nourished.
Orineted to time, place and person.
Patinet was drowsy with inappropriate words , GCS- E2 V4 M4.
Pallor,-ve.
Icterus,-ve.
Cyanosis,-ve.
Clubbing,-ve.
Lymphadenopathy,-ve.
Bipedal or facial edema,-ve.
Vitals:
Pluse rate:128beats/min.
Temperature: 98.8°F.
Respiratory rate: 35cycles /min.
Spo2: 97% on 12 liters of O2.
Blood pressure: 80/50mm of Hg.
Systemic examination:
CVS
S1 and S2 heart sounds heard.
No murmurs heard.
Respiratory system
Trachea is central in position.
The patient is dyspneic and wheeze is present.
Tubular breath sounds heard.
Crepts were heard.
CNS
Intact.
Abdomen:
Soft and non-tender
Bowel sounds normal.
Provisional Diagnosis:
Covid 19 pneumonia with HTN, Denovo dm.
Investigations:
Complete blood picture:
Elevated neutrophil and lymphocytic count indicative of infection.
Complete urine examination:
Sugar presence indicative of dm.
Indication of albumin,Red blood cells indicative of acute kidney injury.
C reactive protein:
No indication of inflamation in the body.
Kenton bodies in urine:
Glucose deprivation in body.
X-ray and ct.results: awaited.
Primary diagnosis:
Covid 19 PNEUMONIA with HTN, Denovo dm and AKI.
Treatment plan:
Head end raise.
Hourly monitoring of bp, sop2 , pulse and respiratory rate
IV - Fluids
Iry. Remdesivir. 1000mg i.v OD
Inj. methyl prednisolone 125mg BD
Inj. clexane. 0.4 ml s/c OD
Inj. ceftriaxone 19 m/r.BD
Inj.NAC. 60mg / day in 500ml ns
Tab. Ivermectin 12mg OD
Tab. Aripiprazole -OD
Tab. pulmoclear - BD
Tab - Limcee -POTID
Tab.zincovit-PO DOD
4/06/2021; patient admited to ICU, given 12lits of O2 and 50units of HAI @9pm. Hypotensive -80/50mm of Hg.
05/06/2021; patient's bloodpressure stabled with 130/70mm of Hg. SPo2 stll maintained at 95% with 12 lits of oxygen.
GRBS-time.
538mg/dl-6am.
373mg/dl-9am.
329mg/dl-10am.
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