COVID-19 PNEUMONIA

Vana Mounika
3rd sem, roll no 140

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.
I have 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.
CASE SCENARIO :
A 63 year old patient came to casuality with chief complaints of shortness of breath since 3 days, fever intermittent in nature associated with chills .
HISTORY OF PRESENT ILLNESS:
Patient was asymptomatic 15 days back when he developed fever and generalised weakness, patient experienced SOB since 3 days .
Outside HRCT - 11/ 25
HISTORY OF PAST ILLNESS:
N/K/C/O - HTN and DM
TREATMENT HISTORY :
No usage of drug as now 
PERSONAL HISTORY:
Married 
OCCUPATION - Farmer 
Appetite - Normal 
Non vegetarian
Bowels - Regular
Micturition - normal
No known allergies
Occasional alcohol
FAMILY HISTORY :
NAD
GENERAL EXAMINATION :
No pallor 
No icterus
No cyanosis
No clubbing
No kolionychia
No lymphadenopathy
No edema 
No malnutrition
No dehydration
VITALS :
Temp- afebrile c/f
Pulse rate - 129bpm
Respiratory rate - 22cpm
BP - 90/60 mmHg
SPO2 - 80 %
GRBS : high
SYSTEMATIC EXAMINATION :
CVS :

No Thrills
Cardiac Sounds - S1, S2 +
No cardiac murmurs
Respiratory :
BAE (bronchial artery embolization )+
Dyspnea yes 
Position of trachea - central
Adventia sounds- crepts 
ABDOMEN
shape -schapoid
Hernial orifice normal
No tenderness
No palpable mass
No free fluid 
No bruits
Liver not palpable
Spleen not palpable 
Bowel sounds - yes 
Genitals normal 
CNS
Level of consciousness - drowsiness
Speech normal
Signs of meningeal irritation - no
Cranial nerves intact 
No motor or sensory deficit
CEREBRAL SIGNS 
finger nose in- coordination - no
Heel knee in-coordination - no
Reasons for lack of coordination ???
Gait normal 
INVESTIGATIONS :



PROVISIONAL DIAGNOSIS :
COVID - 19
WHAT DOES CEREBRAL SIGNS INDICATE ???
TREATMENT :









Comments

Post a Comment

Popular posts from this blog

A 21 year old female with anemia

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patient problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence input. This E blog also reflect my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan CASE: 21 year old female came to gm op with chief complaints of easy fatiguability ,light headedness since 7 years  C/o sob since 7 years ( sometimes )  No c/o Fever, burning micturation,vomitings, loose stools  No c/o involuntary move
Read more

PREFINAL OSCE LEARNING POINTS Dec 4th 2023

My blog link -https://140vanamounika.blogspot.com/ Osce questions :                                             1) Dialysis Disequilibrium syndrome?                  Dialysis disequilibrium syndrome (DDS) refers to an array of neurological manifestations seen during or following dialysis, primarily after the new initiation of dialysis.However, it can also be seen in chronic dialysis patients who miss their regular dialysis treatments. This syndrome is thought to arise from fluid shifts during hemodialysis, causing cerebral edema and a wide variety of neurological symptoms. In continuous renal replacement therapies (CRRT), where fluid shift is limited, dialysis disequilibrium syndrome is rarely reported. The common risk factors that predispose a patient to dialysis dysequilibrium syndrome are  First hemodialysis treatment High blood urea nitrogen (BUN) (above 175 mg/dL or 60 mmol/L) before initiation of dialysis Extremes of age – children and elderly Sudden change in dialysis regimen P
Read more

A 60 year male CKD on maintenance hemodialysis

Image
A 60 year male CKD on maintenance hemodialysis with anemia of chronic disease with hypertension. December 03, 2023 This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted A 60 year old male, who is a resident of Nalgonda ,farmer by occupation came with    Chief complaints: -Pedal edema since 3 months -shortness of breath since 20 days - decreased 
Read more