A 50 yr old patient with giddiness, and dry cough.

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-centered online learning portfolio and your valuable inputs in the log. 

Chief complaints;-
A 50 yr old female came to the OPD with the chief complaints of..
Giddiness since 1 week ..  associated with blurring of vision( intermittent).
Dry cough since 2 days
Fever with chills since 1 day...

History of present illness:-
Patient was apparently asymptomatic 2 yrs ago, then she had high grade fever, associated with chills, red coloured urine, burning micturition,which was diagnosed as emphysematous pyelonephritis.
Stenting was done and removed 2 yrs ago.
4 months ago, she had h/o dysuria and red coloured urine seen due to structure urethra for which cystoscopic dialation was done but, the complaint of red urine still persisted for which tab. Translorin was prescribed for 30 days.
5 days back she has h/o high grade fever with chills ( Intermittent) relieving with medication.
Now, patient came to the opd with complaints of ...
giddiness since 1 week associated with blurring of vision, which is intermittent.

Dry cough since 2 days

Fever with chills  one day before , subsided with medication.

After coming to opd patient had one episode of giddiness for 2 mins. No tonic clinic movements of limbs, no frothing, no tongue bites, no post - ictal confusion, followed by 1 episode of vomiting, water as content, so patient was brought to casuality. 1 week back admitted and discharged for fever and vomitings.

Past history:-
No H/O DM, hypertension, asthma , epilepsy, TB.

Personal history:-
Diet: mixed
Appetite: decreased
Bowel and bladder: regular
Speed : adequate
No addictions
General examination:- 
Patient was conscious, coherent, cooperative, moderately built, and moderately nourished.

 No Pallor, no icterus, no cyanosis, no clubbing, no lymphadenopathy.

vitals:-
Temp: 96 F
Pulse rate:-  70
Bp:- 100/60
RR:- 20 cpm
Spo2 :- 98 on room air
Grbs:- 131

Investigations:-
1.Blood urea :- 49
2.Serum creatinine:- 1.4
3.Serum electrolytes:- Na+ - 135
                                     K+ -  4.2
                                    Cl-  99
4.RBS:-89
5.ESR:-120
6.CBP
7.CUE
8.LFT
9.ECG

10. X- ray
11. 2D echo

12. Ultrasound

 Diagnosis:-
Viral pneumonia  - covid RTPCR POSITIVE.
 Treatment:-
1. Inj. Pan 40 mg IV OD 
2. Tab. Dolo 650 mg po qid
3. Inj. Neomol 1 mg IV SOS 
4. Inj. Zofer 4 mg IV BD
5. Grbs 6 th hrly
6. IV fluids  @ 100 ml/ hr
7. Bp / PR charting 4 th hrly
8. Inj. Ceftriaxone 1 g , IV  BD
9. Inj. Optineuron  1 amp  in 100 ml NS 
      IV OD 
10. Tab. Vertin  16 mg  po SOS 
11. Nebulisation with duolin 8 th hrly,
       Budecort 12 th hrly
12. Syp. Grillinctus po BD .









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