11-6-2021
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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
AISHWARYA GANNOJI.
ROLL NO-35.
A CASE DISCUSSION OF FEVER AND SHORTNESS OF BREATH SINCE 3 DAYS:
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.
Following is the view of my case :
Case admitted under unit 2
History was taken by
Dr.A. Vaishnavi Mam PG y2
Dr. M. Vinay Sir PG y1
and helped by the interns
- G.Sai Vittal Sir
- Ch.Rishik Sir
- G.Preethi Mam
- Deekshitha Mam .
CASE PRESENTATION:
CHIEF COMPLAINTS:
• Fever since 3 days.
•Shortness of breath since 3 days.
•decreased urine output since today.
HISTORY OF PRESENT ILLNESS:
•Patient was apparently asymptomatic 3 days back then she developed
1) FEVER: high grade fever with chills and rigor.
2)SHORTNESS OF BREATH: grade 2.
3) DECREASED URINE OUTPUT: She didn't pass urine today morning.
• Cough is present since 3 days which is productive and white coloured.
•No history of vomitings and loose stools.
•She was tested covid positive.
HISTORY OF PAST ILLNESS:
Known case of CKD since 1 year and on conservative management.
No History of HYPERTENSION, DIABETES MELLITUS, EPILEPSY, TUBERCULOSIS,CORONARY ARTERY DISEASE.
PERSONAL HISTORY:
Diet: mixed.
Appetite: Normal
Sleep: Adequate
Bowel : regular
Micturition: decresed since today.
No addictions.
FAMILY HISTORY:
Not significant.
GENERAL EXAMINATION:
Patient is concious, coherent, co-operative.
She is well oriented to time,place and person. She is moderately nourished.
Pallor- present.
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No Edema.
VITALS:
Temperature: Febrile
Pulse rate: 92 bpm
Respiratory rate: 20/min
Blood pressure: 140/90mm Hg
SpO2 at room air: 89%
SYSTEMIC EXAMINATION:
CARDIO VASCULAR SYSTEM:
• S1 and S2 are heard, no murmurs heard.
RESPIRATORY SYSTEM:
• Wheeze -present
• She has diffuse coarse crepts on auscultation.
ABDOMINAL EXAMINATION:
• Soft and non-tender.
Bowel sounds are heard.
No organomegaly.
CENTRAL NERVOUS SYSTEM:
• Intact.
PROVISIONAL DIAGNOSIS:.
Community acquired Pneumonia viral covid 19 with k/c/o CKD on conservative treatment.
TREATMENT:
1) NF - 0.9% NS U.O + 30ml/hr
2) Inj AUGMENTIN 650mg/IV/BD
3) AZITHROMYCIN 500mg/OD
4) Inj pan 40mg/OD
5) 02 inhalation by SPO2 < 95%
6) INJ DEXAMETHASONE 8mgIVBD
7) NEBULISER volin per 8 hrly
8) Inj CLEXANE 20mg/SA/OD
9) monitor BP PR RR
VITALS 23-05-2021:
Pulse rate - 101 bpm
Blood pressure - 100/60 mm Hg
SpO2 - 99% on room air
GRBS -202 mg/dl
RR - 30/min
1.INJ: AUGMENTIN 625 mg IV
2. TAB AZEE 500 mg OD
3. INJ DEXA 8 mg IV OD
4.INJ PAN 40 mg IV OD
5.NEBULISER volin per 8 hrly
6. I/O charting
7.INJ CLEAXANE 20 mg OD
8. Monitor BP, RR,SPO2,RR
9.TAB NODOSIS 550 mg PO BD
VITALS 24-05-2021:
Pulse rate. - 116 bpm
Blood pressure - 110/70 mm Hg
SpO2 - 96% on room air
GRBS -145 mg/dl
RR - 20/min
1 session of HD done yesterday
1.INJ: AUGMENTIN 625 mg IV
2. TAB AZEE 500 mg OD
3. INJ DEXA 8 mg IV OD
4.INJ PAN 40 mg IV OD
5. NEBULISER volin per 8 hrly
6. I/O charting
7.INJ CLEAXANE 20 mg OD
8. TAB NODOSIS 550 mg PO BD
9. Monitor BP, RR,SPO2,RR
VITALS 25-05-2021:
Pulse rate - 94 bpm
Blood pressure - 180/90 mm Hg
SpO2 - 97% on room air
GRBS -252 mg/dl
RR - 32/min
TREATMENT 25-05-2021:
Second section of HD done
1.INJ: AUGMENTIN 625 mg IV
2. TAB AZEE 500 mg OD
3. INJ DEXA 8 mg IV OD
4.INJ PAN 40 mg IV OD
5. NEBULISER volin per 8 hrly
6. I/O charting
7.INJ CLEAXANE 20 mg
8. Monitor BP, RR,SPO2,RR.
26-5-2021 1:35 am:
CPR NOTES
patient was intubated I/V/O And falling saturation and CPR was started according to AHA guidelines
1:00am
Pulse not recordable
BP not recordable
CPR was continued
INJ Adrenaline 1mg in 1 ml
1:05am
Pulse not recordable
BP not recordable
CPR was continued
INJ Adrenaline 1mg in 1 ml
1:10am
Pulse not recordable
BP not recordable
CPR was continued
INJ Adrenaline 1mg in 1 ml.
1:15am
Pulse not recordable
BP not recordable
CPR was continued
INJ Adrenaline 1mg in 1 ml
1:20am
Pulse not recordable
BP not recordable
CPR was continued
INJ Adrenaline 1mg in 1 ml
1:25am
Pulse not recordable
BP not recordable
CPR was continued
INJ Adrenaline 1mg in 1 ml
1:30am:
Pulse not recordable
r BP not recordable
despite the above resuscitation and treatment the patients could not be revived and declared death at 1:30am on 26/05/2021.
I IMMEDIATE CAUSE OF DEATH:
REFRACTORY hypoxia cardiac pulmonary
ANTECEDENT CAUSE OF DEATH:
severe COVID 19 pneumonia CKD stage 5.
I. INVESTIGATIONS:
HEMOGRAM:
BLOOD GROUPING AND Rh TYPING:
HAEMOGLOBIN:
PROTHROMBIN TIME:
ABG:
23-5-2021
24-05-2021
25-05-2021
LIVER FUNCTION TEST:
RENAL FUNCTION TEST:
ANTI HCV ANTIBODY -RAPID:
HIV 1/2 RAPID TEST:
ECG:
DEATH SUMMARY
CI I would like to thank Dr.Rakesh Biswas sir(H.O.D,General Medicine) for giving me this opportunity.
Comments
Post a Comment