65 year old male with diffuse involuntary movements of left lower limb

 This is an 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 

—————————————————————————————————

Case details

A 45 year old male has presented with the casuality with the chief complaints of sudden onset shortness of breath on 2nd June 2021

History of presenting illness

The patient was apparently asymptomatic till June 2nd .

Then he developed grade 4 SOB which is of sudden onset.

There was a history of orthopnea

No history of fever, cough, cold, sore throat, loss of appetite, chest pain, palpitations, giddiness, sweating, blurring of visions, blackout

Based on the above history he was sent for rapid antigen test for covid-19 which he was tested positive on 2nd June 2021 and then he was admitted in COVID ICU 

History of past illness

No history of diabetes hypertension tuberculosis or epilepsy

Personal history 

Appetite : normal

Diet : mixed

Bowel and bladder habits: regular

Sleep : adequate

Addictions: No addictions

No history of drug and food allergies

Family history: not significant

General examination 

The patient is conscious for rent in cooperative

He is well oriented to time place and person

Moderately built and moderately nourished

Pallor: absent

Icterus:absent

Cyanosis:abent

Clubbing:absent

Lymphadenopathy: absent

Edema: absent 

Vitals

Temperature: afebrle

Pulse:  132bpm

Respiratory rate:33cpm

Blood pressure: 90/60 mmHg

SPO2:91 on room air

GRBS:100mg%

Systemic examination:

Cardiovascular system: s1 s2 heard,  No thrills and murmurs

Respiratory system;

• DYSPNEA ; PRESENT
• BILATERAL CREPTS 

Abdomen: SOFT and NON TENDER

CNS: NAD

Provisional diagnosis: VIRAL PNEUMONIA SECONDARY TO COVID -19 

Investigations

INVESTIGATIONS

HEMOGRAM:   INCREASE IN NEUTROPHILS.

ESR : ELEVATED

RFT: ELEVATED UREA 

D DIMER 

LFT: ELEVATED ALP 

HRCT THORAX 

TREATMENT :

ON 2ND JUNE 2021

1. NEB. BUDECORT+DUOLIN 8TH HOURLY
2. TAB. PARACETAMOL500mg PO/SOS
3. TAB.PANTOP 40mg PO/OD
4. TAB.LIMCEE OD
5. TAB.ZINCOVIT OD
6. O2 SUPPLEMENTATION @10L/MIN  MAINTAINING AT SPO2 92%
7. CONTINUOUS MONITORING OF BP ,SPO2 AND GRBS

ON 3RD JUNE 2021 

1. O2 SUPPLEMENTATION TO MAINTAIN SPO2 >92%
2. TAB.PCM 650MG PO SOS
3. TAB PANTOP 40 MG PO OD\TAB. LIMCEE PO OD
4. TAB MVT PO OD 
5. NEB. WITH DUOLIN +BUDECORT  8TH HOURLY
6. TAB. AUGMENTIN  625MG /PO/BD
7. CONTINUOUS MONITORING

ON 4TH JUNE 2021

1. O2 SUPPLEMENTATION
2. TAB AUGMENTIN 625MG BD
3. TAB LIMCEE OD
4. TAB ZINCOVIT OD
5. TAB PANTOP 40 MG OD 
6. TAB DOLO 650 MG BD
7. NEBULIZATION WITH DUOLIN +BUDECORT 8TH HOURLY