A 65 YEAR OLD FEMALE WITH FEVER, SHORTNESS OF BREATH, DRY COUGH AND GENERALISED WEAKNESS

SUDHAMSHI REDDY M

MBBS 8th semester

Roll no:80

This is 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 patients 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 on comment box is welcome .

 

I’ve been given this case to solve in an attempt to understand the topic of “patient 

clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.

Following is the view of my case...

CASE:

A 65 year old female came to the OPD on 5th of May with chief complaints of 

• FEVER since 4 days
• DRY COUGH since 4 days
• GENERALISED WEAKNESS since 4 days
• DIFFICULTY IN BREATHING since 1 day    

HISTORY OF PRESENTING ILLNESS:   

Patient was apparently asymptomatic 4 days back when she developed

-Fever which was insidious in onset, intermittent in nature, not associated with chills and rigors.

- Dry cough which was insidious in onset, intermittent in nature, with no diurnal or positional variations. No aggravating or relieving factors were noted.

-Fatigue which was insidious in onset, gradual in progression with no aggravating factors.

-She developed Grade 2 shortness of breath (NYHA CLASSIFICATION) a day ago, insidious in onset and gradual in progression.

No complaints of vomitings, chest pain, loss of smell and taste.

PAST HISTORY:

K/C/O Hypertension since past 10years on medication.

K/C/O Diabetes mellitus since past 5years on medication(Tab. Glimiperide 1mg / OD)

K/C/O CVA 7years back, with deviation of mouth and slurring of speech.

PERSONAL HISTORY:

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder movements: regular

Addictions: none

DRUG HISTORY:

Takes Tab.Glimiperide-M1 1mg/OD

Takes oral antihypertensive medication(unknown)

Took Tab.Doxycycline 100mg, Tab. Ivermectin 12mg, Tab.Methylprednisolone 16mg/BD for 4 days before arriving at the hospital.

FAMILY HISTORY:

No history of similar complaints in the family.

No history of Diabetes, Tuberculosis, Stroke, Asthma, any other hereditary diseases in the family.

GENERAL EXAMINATION: 

The patient is examined in a well lit room, with informed consent

The patient is conscious, coherent, cooperative, is well oriented to time, place, person.

She is moderately built and nourished.

Pallor : absent

Icterus : absent

Cyanosis : absent

Clubbing : absent

Lymphadenopathy : absent

Edema : absent

VITALS:

 On the day of admission-5/05/2021 

 Temperature-99°F

 Heart rate-92 beats/min

 Blood pressure-130/80 mmHg

 Respiratory rate-18 cycles/min

 SPO2-93% at room air 

            

6/05/2021

Temperature-99°F

Heart rate-78 beats/min

Blood pressure-110/70 mmHg

Respiratory rate-19 cycles/min

SPO2-89% at room air

           95%with 4litres of O2

07/05/2021

Temperature-98.6°F

Heart rate-76beats/min

Blood pressure-140/70 mmHg

Respiratory rate-18 cycles/min

SPO2-94% on 10litres of O2

08/05/2021

Temperature-98°F

Heart rate-100beats/min

Blood pressure-130/80 mmHg

Respiratory rate-18 cycles/min

SPO2-56% at room air

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard

         No added thrills, murmurs

RESPIRATORY SYSTEM: Normal vesicular breath sounds heard

PER ABDOMEN: soft, non tender, no organomegaly

CNS: intact

INVESTIGATIONS:     

      COMPLETE BLOOD PICTURE       

          

       Hemoglobin-11.7gm/dl

          Total count-14000cells/cu mm

          Neutrophils-70%

          Lymphocytes-25% 

          Monocytes-4%

          Eosinophils-1%

          Basophils-0%

          Platelet count-25,000/cu mm

          Smear- Normocytic normochromic with leucocytosis and thrombocytopenia 

        

         

       LIVER FUNCTION TEST

         Total Bilirubin-0.86mg/dl

         Direct Bilirubin-0.14mg/dl

         SGOT(AST)-30 IU/L

         SGPT(ALT)-35 IU/L

         Alkaline phosphatase-130 IU/L

         Total proteins-6.5 gm/dl

         Albumin-3.6 gm/dl

         A/G ratio-1..41

     RENAL FUNCTION TEST

      Urea-31mg/dl

      Creatinine-0.4mg/dl

      Uric acid-2.1mg/dl

      Calcium-9.5mg/dl

      Phosphorous-2.0mg/dl

      Sodium-134mEq/L

      Potassium-3.2mEq/L

      Chloride-100mEq/L

  ARTERIAL BLOOD GAS

    PH-7.43

    PCO2-30.9

    PO2-41.7

    HCO3-20.4

    St.HCO3-21.6

    BEB- -2.5

    BEecf- -3.2

    TCO2-40.9

    O2 Saturation-59.2

   O2 Count-10.8

LOW O2 SATURATION

      

  CXR

ECG REPORTS

07/05/2021

PROVISIONAL DIAGNOSIS:

Viral pneumonia secondary to COVID-19 INFECTION.

TREATMENT REGIMEN:

During the stay in the hospital-

1. O2 inhalation to maintain SPO2>90%

2. Tab PANTOP 40mg/PO/OD

3. Tab. PARACETAMOL 650mg/PO/OD

4. Tab GLIMIPERIDE-M11mg/PO/OD

5. Tab METHYLPREDNISOLONE 16mg/PO/OD

6. Tab MVT/OD

7. Nebulisation with Budecort, Duolin -8th hourly

8. Syrup. Grilinctus-10ml/TID

9. Tab MET-XL 50mg/PO/OD

10. Inj Dexamethasone 6mg/IV/OD) 

11. GRBS monitoring

12. BP, PR, SPO2 monitoring 6th hourly

Despite all the above measures, on day 4 of hospital stay the SPO2 levels kept falling, pulse was not recordable. ECG has shown a flat isoelectric line and the patient was declared dead.

08/05/2021

Immediate cause of death- CARDIO PULMONARY ARREST

Antecedent cause of death- ARDS 2° TO COVID 19

QUESTIONS-

1) What can be the causes of early progression and aggressive disease among diabetics when compared to non diabetics?

2) In a patient with diabetes and steroid use what treatment regimen would improve the chances of recovery?

3)What affect does a history of CVA have on COVID prognosis?

Under the guidance of Dr. Sai Charan sir.