Fever(since 1 week)
Cough(since 1 week)
SOB(since 2 days)
Patient was apparently asymptomatic 1 week back and developed fever associated with chills and rigor,dry cough, general weakness, No diurnal variation. He has also been experiencing dyspnea on exertion, Grade 3, since 2 days
There was history of similar complaints inthe past where fever was associated with hematemesis(acc. To patient attender) due to which he was admitted to a hospital in kodad and got treated
He was diagnosed as diabetes since 3 years(through a camp) and is on regular medication
Personal history
1. Married
2. Decreased appetite
3. Vegetarian
4. Normal bowel and bladder
5. Was a alcoholic(90ml/day) and smoker (1 pack/day) 11yrs back
No significant family history
No significant drug history
O/E
Pt is c/c/c
Vitals:
BP: 100/50mmhg
PR: 90/min
SpO2:91%@RA
GRBS: 159mg/dl
Systemic examination :
CVS:S1,S2 heard
Apex beat:5th ICS
Resp:
BAE+(vesicular breath sounds)
Nvbs heard
Position of trachea- central
P/A : soft , Non-tender
Provisional diagnosis
Viral Pyrexia (RTPCR+VE FOR COVID-19)
Investigations:-
1.Sr.Electrolytes
Na+. 141
K+. 4.4
Cl-. 106
2.Sr. Creatinine- 1.5
3.LFT
Tb-1.20
Db-0.42
Ast-120
Alt-56
Alp-83
TP-4.8
ALBUMIN-2.5
A/G- 1.64
4. Hemogram
Hb-11.7
TLC-9500
N-56
L-11
E-02
B-00
PCV-46.5
MCV -79.4
MCH -27.2
RBC.-5.86
PLT-1.65L
5. uric acid-5.0
6. RBS-148
7. Cr. Cl -11ml/hr
8. RTPCR (COVID-19) - +VE
9. 2D -Echo
10. X-Ray
Treatment Given:
1) INJ. AUGMENTIN 1.2gm IV/BD
2) IVF RL &NS @ 150 mL/hr
3) HEAD END FLEVATION
4) 0₂ INHALATION TO MAINTAIN SpO2≥94%
5 INJ.PANTOP 40mg IV/OD
6) INJ. NEOMOL 1.9m Iv/sos (If Temp>100f)
7) TAB.AZEE 500mg PO/OD
8) TAB PCM 650mg Po/TID.
9) NEB WITH BUDECORT - 6th HRLY DUOLIN - 8th HRLY
10) INI HAI ACC TO SLIDING SCALE
Patient was referred to higher center I/V/O RTPCR+ve for covid-19
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