55 year old female with viral pneumonia secondary to COVID-19
June 12th 2021
Student Name- D.Vineesha Chowdary
2017 Batch
Roll no.- 24
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 centered online learning portfolio and your valuable inputs on comment box is welcome.
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.
A 55 year old female with viral pneumonia secondary to COVID-19
Following is the view of my case:
CHIEF COMPLAINTS:
A 55 yr old woman presented to the OPD on 9/05/21 with chief complaints of:
- Myalgia since 1 week
- Fever since 3 days
- Shortness of breath since 3 days.
-H/O Kidney surgery on the left side for renal calculi.
-H/O of hysterectomy 10 years back.
Rx-
- O2 inhalation to maintain SpO2 > 90%
-T.PCM 650mg P/O SOS
- Duolin, Budecort nebulisation every 8 hours
- GRBS every 8 hours
- Monitor PR, BD, SpO2 every hour
-Tab. GLIZID-M 80/500mg BD
(On 10/5/21):
Rx-
- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)
- Inj Clexane 40mg SC OD
- Inj Pantop 40mg IV/BD
- IVF -20NS at 75ml/hour
- Tab Glizid 80/500mg PO BD
- Duolin, Budecort nebulisation every 6 hours
- GRBS every 8 hours
- Temp charting 4 hourly
- Monitor PR, BD, SpO2 every hour
- Tab Oseltamivir 75mg BD
- Encourage oral fluids
-Head end elevation
-Tab Lime PO OD
-Tab Dolo 650mg PO SOS
- Temp Charting every 4 hours
(On 11/5/21):
Rx-
- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)
- Inj Clexane 40mg SC OD
- Inj Pantop 40mg IV/BD
- IVF -20NS at 75ml/hour
- Tab Glizid 80/500mg PO BD
- Duolin, Budecort nebulisation every 6 hours
- GRBS every 8 hours
- Temp charting 4 hourly
- Monitor PR, BD, SpO2 every hour
- Tab Clinidipine 10 mg OD
- Encourage oral fluids
-Head end elevation
-Tab Lime PO OD
-Tab Dolo 650mg PO SOS
- Temp Charting every 4 hours
-Inj. Dexamethasone 8 mg IV/OD
(On 12/5/21):
Rx-
- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)
- Inj Clexane 40mg SC OD
- Inj Pantop 40mg IV/BD
- IVF -20NS at 75ml/hour
- Tab Metformin SR 750mg PO BD
- Duolin, Budecort nebulisation every 6 hours
- GRBS every 8 hours
- Temp charting 4 hourly
- Monitor PR, BD, SpO2 every hour
- Tab Clinidipine 10 mg OD
- Encourage oral fluids
-Head end elevation
-Tab Lime PO OD
- Temp Charting every 4 hours
-Inj. Dexamethasone 8 mg IV/OD
-Tab MVT PO OD
(On 13/5/21):
Rx-
- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)
- Inj Clexane 40mg SC OD
- Inj Pantop 40mg IV/BD
- IVF -20NS at 75ml/hour
- Tab Metformin SR 750mg PO BD
- Duolin, Budecort nebulisation every 6 hours
- GRBS every 8 hours
- Temp charting 4 hourly
- Monitor PR, BD, SpO2 every hour
- Tab Clinidipine 10 mg OD
- Encourage oral fluids
-Head end elevation
-Tab Lime PO OD
- Temp Charting every 4 hours
-Inj. Dexamethasone 8 mg IV/OD
-Tab MVT PO OD
(On 14/5/21):
Rx-
- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)
- Inj Clexane 40mg SC OD
- Inj Pantop 40mg IV/BD
- IVF -20NS with 1 amp of optineuron
- Tab Metformin SR 750mg PO BD
- Duolin, Budecort nebulisation every 6 hours
- GRBS every 8 hours
- Temp charting 4 hourly
- Monitor PR, BD, SpO2 every hour
- Tab Clinidipine 10 mg OD
- Encourage oral fluids
-Head end elevation
-Tab Lime PO OD
- Temp Charting every 4 hours
-Inj. Dexamethasone 8 mg IV/OD
-Tab MVT PO OD
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