Saturday, May 22, 2021

A 72-year-old male patient with viral pneumonia secondary to COVID-19


"This is an online E logbook 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 the 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 logbook also reflects my patient-centered online learning portfolio and your valuable comments in the comment box are welcome.

 


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Tondapu Sreelekha, 8th semester

Roll no. – 135

 

 

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 a diagnosis and treatment plan. 

 

 

Following is the view of my case: (history as per date of admission)




 

CASE

A 72-year-old male came to the OPD with chief complaints of shortness of breath, fever and low oxygen levels.

 

 

HISTORY OF PRESENTING ILLNESS

·         The patient was apparently asymptomatic 3 days ago, when he developed shortness of breath (grade IV- NYHA classification ) which was insidious in onset, and rapid in progression with no aggravating factors.

·         He also developed a fever 3 days ago which was insidious in onset. It was of high grade, intermittent and was not associated with chills and rigors. 

·         He did not have any complaints of cough, chest pain, loss of smell or taste, diarrhoea, headache. 

PAST HISTORY

·         No similar complaints in the past.

·         He is a known case of hypertension for the past 20 years. Currently under treatment (Tablet Losar-H 50/12.5 mg and Tablet Cinod 20mg)

 

 

PERSONAL HISTORY

·         DIET- Mixed

·         APPETITE- Lost

·         SLEEP- Adequate

·         BOWELS- Regular

·         MICTURATION- Normal

·         ADDICTIONS- None

·         ALLERGIES- None

 

FAMILY HISTORY

·         There is no significant family history.

·         No other member of his family has been tested COVID positive.

 

 

GENERAL EXAMINATION

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

He is moderately built and moderately nourished.

·         No pallor

·         No icterus

·         Central and peripheral cyanosis is present

·         No clubbing

·         No generalized lymphadenopathy

·         No pedal oedema

 

 

VITALS

·         Temperature: febrile

·         Pulse: 104 beats/mins

·         Blood pressure: 130/80 mmHg

·         Respiratory rate: 24 cycles/min

·         SpO2: 85% at 15 Lit of O2

 

SYSTEMIC EXAMINATION

 

CVS

·         S1 and S2 heart sounds heard.

·         No murmurs heard.

Respiratory system

·         Trachea is central in position.

·         The patient is dyspneic and wheeze is present.

·         Tubular breath sounds heard.

·         Crepts were heard.

CNS

Intact

Abdomen

·         Soft and non-tender.

·         Bowel sounds were heard.

·         No organomegaly.

 

 

INVESTIGATIONS

LFT

  •     Total bilirubin : 0.76 mg/dl
  •        Direct bilirubin : 0.27 mg/dl
  •          SGOT : 31 IU/L
  •          SGPT : 18 IU/ L
  •          ALP : 130 IU/L
  •          Total proteins : 5.8gm/dl
  •          Albumin: 303gm/dl
  •          A/G ratio: 1.31


 

RFT

 

·         Blood urea : 38 mg/dl

·         Serum creatinine : 1.2 mg/dl

·         Uric acid: 4.8 mg/dl

·         Calcium : 9.7 mg/dl

·         Phosphorus : 2.6 mg/dl

·         Sodium : 136 mEq/L

·         Potassium : 3.7 mEq/L

·         Chloride : 102 mEq/L

 


 

 

ABG

·         pH - 7.28

·         pCO2 – 29.3mm Hg

·         pO2 – 45.4 mm Hg

·         HCO3 – 21.6 mmol/L

·         BEB -  –0.7 mmol/L

·         BEecf - –1.4 mmol/L

·         TCO2 – 43.9 VOL

·         O2 Sat – 83.6%




Haemoglobin: 11.3gm/dl

Ferritin: 254 mcg/L

TLC: 13,300 cells/microL

CRP: 2.4 mg/dl (positive)

X-ray



ECG



Provisional Diagnosis:  VIRAL PNEUMONIA SECONDARY TO COVID-19 {severe}

 

Treatment given:

Inj. Pan 40mg IV OD

Inj. Dexamethasone 8mg IV TID

IVF 10 ns optineuron, 10rl thiamine @ 100ml/hr

Tab. Dolo 650mg p/o TID

Head end elevation to 30 degree

GRBS charting 6th hourly

Intermittent BIPAP at physicians’ call

Nebulization with duolin, budecort, mucomyst 8th hourly.

Monitor temperature, SpO2, PR, BP 4th hourly.

 

Despite all the above measures, the patient died on day 5 of hospital stay (day 8 of symptoms).

 The Immediate cause of death- Cardiopulmonary arrest

 Antecedent cause: COVID-19 pneumonia




 


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