First visit to doctor: 09/06/2021
Haji Hassan son of Mohammad Rasool 40 years old patient living in Qale-Fateh Ullah Came to Dewanbegi Clinic with chief complain of fever/6days, sore throat, body pain and dyspnea.
Vital sign
Temperature 37.8 Heart rate 85
Respiratory rate 26 Blood pressure 100/70
So2 85% Weight 78kg Height 182cm
Mr. Haji Hassan has history of diabetes mellitus since few years ago (about 4 year).
In physical examination, patient was alert, mouth was dry, with audible chest crepitation.
Impression diagnosis: suspected covid-19 + DM
Treatment: because patient had come only for oxygen therapy oxygen therapy is started along with continuation of drug he is taking.
2nd visit of doctor: 15/06/2021
Haji Hassan son of Mohammad Rasool 40 years old patient living in Qale-Fateh Ullah Came to Dewanbegi Clinic with chief complain sever dyspnea, drowsy.
Vital sign
Temperature 37.6 Heart rate 114
Respiratory rate 30 Blood pressure 100/60
So2 53%
In physical examination patient was in respiratory distress and irritable.
Impression diagnosis: suspected covid-19 + DM
Treatment:
- O2 therapy 10L/mint
- Serum. N/S 500 cc
- Amp. Vit C
- PCM(Amp. Paracetamol 750mg)
- Amp.Methyl prednisolone 100mg/ inf.NS 100cc
Because the patient was not in our management set up, he was advised to go to COVID-19 specialized hospital to be admitted, because our services were from 8am to 7pm and patient needed 24hr evaluation.
But due to high number of COVID-19 cases, they were unable to find any bed to be admitted; thus, they requested the clinic administration if we could prepare them 24hr bed facility.
Thus the clinic administration toke decision to admit their patient for 24hr in the clinic.
So, the following treatment have been given to the patient:
- O2 10L/min
- Enoxaparin 8000unit BID SC
- Amp.Methyl prednisolone 100mg BID/inf.NS 100cc
- Tab.Getryl 2mg OD
- Tab.Glucophage 500mg BID
- Amp.Paracetamol 1gr PRN
FOLLOW UP 16/06/2021
Vital sign
Temperature 38.4 Heart rate 113
Respiratory rate 27 Blood pressure 110/70
So2 82%
Investigation
S.D-Dimer 8991.17 ng/ml
S.FBs 120mg/dl
Lymphocytes count LOW
Medication Order
- O2 8L/min
- Amp.paracetamol 1gr PRN
- Vial.Vancomycine 1gr BID/100cc NS/30 mint
- Vial. Meropenium 1gr BID/1000cc NS
- Tab. Methyl prednisolone 44mg BID 25% tapered dose after 3 day.
- Rivaroxoban 20mg OD
FOLLOW UP 17/06/2021
Vital sign
Temperature 38.4 Heart rate 113
Respiratory rate 27 Blood pressure 110/70
So2 82%
Medication Order
- O2 8L/min
- Amp.paracetamol 1gr PRN
- Vial.Vancomycine 1gr BID/100cc NS/30 mint
- Vial. Meropenium 1gr BID/1000cc NS
- Tab. Methyl prednisolone 44mg BID 25% tapered dose after 3 day.
- Rivaroxoban 20mg OD
- Tab.furesomide 20mg PRN
FOLLOW UP 19/06/2021
Chief complain cough, dyspnea, dizziness
Vital sign
Temperature 36 Heart rate 63
Respiratory rate 23 Blood pressure 90/60
So2 80%
Medication Order
- O2 8L/min
- Amp.paracetamol 1gr PRN
- Vial.Vancomycine 1gr BID/100cc NS/30 mint
- Vial. Meropenium 1gr BID/1000cc NS
- Tab. Methyl prednisolone 33mg BID 25% tapered dose after 3 day.
- Rivaroxoban 20mg OD
- Tab.furesomide 20mg PRN
FOLLOW UP 20/06/2021
Patient feel better than yesterday and didn’t have active complain vital sign are as following
Vital sign
Temperature 36 Heart rate 79
Respiratory rate 22 Blood pressure 109/60
So2 90%
Medication Order
- O2 8L/min
- Amp.paracetamol 1gr PRN
- Vial.Vancomycine 1gr BID/100cc NS/30 mint
- Vial. Meropenium 1gr BID/1000cc NS
- Tab. Methyl prednisolone 33mg BID 25% tapered dose after 3 day.
- Rivaroxoban 20mg OD
- Tab.furesomide 20mg PRN
FOLLOW UP 21/06/2021
Vital sign
Temperature 36 Heart rate 79
Respiratory rate 22 Blood pressure 109/60
So2 90%
Medication Order
- O2 7L/min
- Amp.paracetamol 1gr PRN
- Vial.Vancomycine 1gr BID/100cc NS/30 mint
- Vial. Meropenium 1gr BID/1000cc NS
- Tab. Methyl prednisolone 33mg BID 25% tapered dose after.
- Tab.Rivaroxoban 20mg OD
- Tab.furesomide 20mg PRN
FOLLOW UP 22/06/2021
Vital sign
Temperature 36.2 Heart rate 82
Respiratory rate 20 Blood pressure 90/50
So2 95%
Investigation
S.D-Dimer 4338ng/
S.FBs 116mg/dl
CRP.12mg/dl
Medication Order
- O2 5L/min
- Amp.paracetamol 1gr PRN
- Vial.Vancomycine 1gr BID/100cc NS/30 mint
- Vial. Meropenium 1gr BID/1000cc NS
- Tab. Methyl prednisolone 25mg BID 25% tapered dose after 3 day.
- Tab.Rivaroxoban 20mg OD
- Tab.furesomide 20mg PRN
FOLLOW UP 23/06/2021
Vital sign
Temperature 36.2 Heart rate 58
Respiratory rate 22 Blood pressure 100/70
So2 96%
Medication Order
- O2 4L/min
- Amp.paracetamol 1gr PRN
- Vial.Vancomycine 1gr BID/100cc NS/30 mint
- Vial. Meropenium 1gr BID/1000cc NS
- Tab. Methyl prednisolone 25mg TID 25% tapered dose after 3 day.
- Tab. Rivaroxoban 20mg OD
- Tab.furesomide 20mg PRN
FOLLOW UP 24/06/2021
Vital sign
Temperature 36.2 Heart rate 58
Respiratory rate 23 Blood pressure 110/70
So2 96%
Medication Order
- O2 4L/min
- Amp.paracetamol 1gr PRN
- Vial.Vancomycine 1gr BID/100cc NS/30 mint
- Vial. Meropenium 1gr BID/1000cc NS
- Tab. Methyl prednisolone 25mg TID 25% tapered dose after 3 day.
- Tab. Rivaroxoban 20mg OD
- Tab.furesomide 20mg PRN
FOLLOW UP 25/06/2021
Today patient wants to be discharged with medication, doctor advised him if he find any danger symptom should go to doctor. Now, the patient is discharged with following medication.
- O2 2L/min
- Tab.Rivaroxoban 20mg od for 3days
- Tab.Moxifloxacine 400mg OD
- Tab.Osnate D OD
- Surbex Z OD
- Tab.Paracetamol 650mg TID
Patient is advised the following investigation.
D-dimer =2519.26ng/ml
CRP=06
FBS=79