61 YEAR OLD FEMALE WITH FEVER , COUGH , SOB AND VOMITING

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MUSKAAN GOYAL

ROLL NO. 92, 8TH SEM

MAY 26,2021

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 diagnosis and treatment plan. 

(Contains information collated from Dr.CHANDANA PG and from the patient)

CASE DISCUSSION:

A 61 yr female pt. , farmer by occupation , resident of chandanpet  presented to the Opd on 25/5/2021 with chief complaints of 

FEVER SINCE 5 DAYS

VOMITING SINCE 3 DAYS

COUGH SINCE 2 DAYS 

SHORTNESS OF BREATH SINCE AFTERNOON 

HISTORY OF  PRESENT ILLNESS:

Pt. was apparently asymptomatic 5 days back and the she  suddenly developed ,

fever which was sudden in onset , intermittent in nature , on and off with chills and rigor and relieved on medication . Pt. took self prescribed medication for fever . ( TAB. DOLO ).

fever is associated with body pains.

vomiting  since 3 days 3episode per day which is mostly after intake of solid food , content being the food taken . not associated with pain abdomen and loose stools.

cough since 2 days which was sudden in onset  , non productive , and no aggravating and relieving factors.

SOB since afternoon  which is grade 3 . NO H/O orthopnea and PND. did not  take any oxygen inhalation

NO H/O pedal edema , facial puffiness and burning micturition. 

HISTORY OF PAST ILLNESS:

Pt. developed fever 5 days back , for which she started taking TAB . DOLO ( self prescribed) for 2 days .

 

After that she has unbearable body pains following which she got a covid-19 test done which came out positive ,following that she took TAB. DOLO , TAB. DOXYCYCLIN and TAB. LIMCEE ( all self prescribed ). 

she  then developed SOB  for which they consulted a doctor near by who advised for a HRCT scan  which showed lung damage . 

Following this , the pt. was brought to KIMS yesterday night.( 25/5/2021).

No H/O DM , HTN , epilepsy , CAD , CNA , TB , CKD .

FAMILY HISTORY :

Patient's husband has also been tested covid-19 positive and is on medication and in  home isolation.

PERSONAL HISTORY:

diet - mixed 

appetite- reduced since 3 days

sleep- disturbed due to body pains since 3 days

bowel and bladder - regular

addictions- no addictions

GENERAL EXAMINATION:

Pt. is C/C/C

heavily built and obese

NO pallor , cyanosis , icterus , clubbing , lymph adenopathy , edema

obese with central obesity.

VITALS ON THE TIME OF ADMISSION:

temperature - afebrile

PR- 120 beats per min

RR-28 cycles / min

BP - not recorded

SPO2 - 75% at ROOM AIR

SYSTEMIC EXAMINATION:

CVS: 

S1 S2 heard . no murmurs

RESPIRATORY SYSTEM :

B/L coarse crepts present

dyspnea present 

centrally place trachea

no wheeze

CNS :

no abnormal defects

ABDOMEN:

soft and non tenser

bowel sounds normal.

INVESTIGATIONS:

pt. has got HRCT  done in other diagnostic center before coming to the hospital.

COURSE IN HOSPITAL :

25/ 5/2021:( day of admission)

Pt. was examined and started on medication and oxygen inhalation to maintain spo2 above 92%

INVESTIGATION : blood reports and ECG advised.

26/5/2021:( day 5 of illness)

Pt. complains of epigastric pain after breakfast. 

 

VITALS :

temperature: afebrile

BP: 120/90MMHG

RR: 21 cycles per min

PR- 76 beats per  min

spo2 - 91 on 15lt of oxygen .

grbs- 149mg/dl

INVESTIGATION : advised for serum ferritin , LDH ,  repeat ECG.

BLOOD REPORTS AND ECG REPORTS:

TREATMENT BEING GIVEN.

27/5/2012: ( day 6 of illness)

CT SEVERITY SCORE - 15/25( according to 25/5/21)

CORADS-5

ON BIPAP.

O/E -Pt. is C/C/C

vitals  at 8:00 am :

temperature : afebrile

PR: 102bpm

BP: 110/70mmhg

GRBS: 159mg/dl

spo2 : 83 % on continuous BIPAP

CVS : s1s2 +

R/S : BAE +

P/A :soft and non tender with no organomegaly.

CNS- HMF intact

NO pedal edema , jaundice .

INVESTIGATION ADVISED TODAY IS 2D ECHO.

TREATMENT TODAY:

28/5/2021:(day 7 of illness)

CT SCORE -15/25

CORADS - 5

8 am:

O/E -pt. is C/C/C

afebrile

PR- 101bpm

BP- 110/70mmhg

RR- 20cycles/min

spo2- 79% on ROOM AIR

          90% ON NRBM at 15lt of oxygen

GRBS- 136mg/dl

CVS- s1s2 heard 

R/S- BAE + 

P/A- soft and non tender with no organomegaly

CNS- HMF intact

no pedal edema , jaundice .

investigation advised today is D-dimer  and CRP

treatment being given: