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A 38 year old male came with chief complaints of fever since 2 weeks & difficulty in breathing since 7 days and he was tested positive for RAT COVID , HRCT chest CORADS 6
HOPI :
Patient was apparently asymptomatic 14 days back then developed high grade fever not associated with chills & rigors and not relieved on medication for the first 3 days. Then it subsided with medication. Then developed difficulty in breathing which is of grade 2
PAST HISTORY:
- known case of hypertension since 3years and was on medication ( telma- H)
- No history of diabetes mellitus, T.B , epilepsy, asthma.
PERSONAL HISTORY:
Diet - mixed
Appetite- normal
Bowel & bladder - regular
Sleep- adequate
Addictions- none
No known drug allergies
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative
No pallor, icterus, cyanosis, clubbing, Lymphadenopathy, Edema.
VITALS:
PR-86 bpm
BP- 130/70 mmHg
RR- 18 cpm
Temperature- Afebrile
Spo2- 94 room air
SYSTEMIC EXAMINATION:
CVS: S1, S2 heard, no murmurs
RS: dyspnoea - grade2 , position of trachea is central, vesicular breath sounds heard , no added sounds
P/A: scaphoid shape, soft, non tender, bowel sounds heard
CNS: NAD
PROVISIONAL DIAGNOSIS:
Viral pneumonia secondary to COVID 19
INVESTIGATIONS ORDERED:
CBP , RFT, LFT, ABG,ECG, D- DIMER, CXR- PA VIEW
TREATMENT GIVEN:
1. O2 inhalation to maintain SPO2 > 92%
2. IVF- NS with optineuron @ 75 ml/ hr
3.INJ.PANTOP40 mg IV OD
4. Tab dexamethasone 4 mg PO BD
5.Tab LIMCEE PO OD
6. Tab Telma-H 40/12.5 mg PO OD
7. GRBS monitoring 8th hrly
8. BP, PR, SPO2 monitoring hrly
On day 18/5/2021:
VITALS:
patient conscious, coherent, cooperative
PR- 83 bpm
BP- 120/80 mm Hg
Spo2 - 96 % RA
Temperature: Afebrile
TREATMENT:
1. O2 inhalation to maintain SPO2 > 92%
2. IVF- NS with optineuron @ 75 ml/ hr
3.INJ.PANTOP40 mg IV OD
4. Tab dexamethasone 4 mg PO BD
5.Tab LIMCEE PO OD
6. Tab MVT PO OD
7. Tab Telma-H 40/12.5 mg PO OD
8. GRBS monitoring 8th hrly
9. BP, PR, SPO2 monitoring hrly
On 19/5/2021:
VITALS:
Conscious, coherent, cooperative
PR- 84bpm
BP- 110/70 mmHg
Spo2 96% on RA
Temperature - Afebrile
TREATMENT:
1. O2 inhalation to maintain SPO2 > 92%
2. IVF- NS with optineuron @ 75 ml/ hr
3.INJ.PANTOP40 mg IV OD
4. Tab dexamethasone 4 mg PO BD
5.Tab LIMCEE PO OD
6. Tab MVT PO OD
7. Tab Telma-H 40/12.5 mg PO OD
8. GRBS monitoring 8th hrly
9. BP, PR, SPO2 monitoring hrly
