General medicine case discussion

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Viral pneumonia secondary to covid 19 infection


Name             : Lasya Sakilam
Roll num       : 117
       

     This is online E log book to discuss out patients de-identified health data shared after taking his / her guardian`s 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 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 comments box is welcome.

       I have 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 options

Following is the view of my case :

case discussion:

A 45 yr old male came to opd on 4 May 2021 with complaints of 

  1. FEVER since 4 days
  2. LOOSE STOOLS since 2 days 
  3. COUGH since 1 day 
  4. DIFFICULTY IN BREATHING since 1 day 
HOPI : Patient was apparently asymptomatic 4 days back then he developed fever since 4 days which subsided one day back . 

He has complaints of loose stools since 2 days , four episodes on 3 rd may and two episodes on 4 may . 

Patient has complaints of cough with expectoration since 1 day 

Dyspnea :  grade 2 (NYHA ) 

No complaints of vomiting's , chest pain , palpitations , sweats .

PAST HISTORY  : 
  • NOT k/c/o hypertension 
  • Not k/c/o diabetes mellitus
  • Not k/c/o epilepsy, asthma, TB, CVA.
PERSONAL HISTORY:
  • DIET: Mixed
  • APETITE: Normal
  • SLEEP: Adequate
  • BOWEL & BLADDER : diarrhea from 2 days 
  • ADDICTIONS : None
FAMILY HISTORY :
  • No history of similar complaints in the family
  • No history of DM, hypertension, TB, stroke, asthma, epilepsy.
  • No H/O of any hereditary disease in family
GENERAL EXAMINATION : 
        The patient is examined in a well lit room, with informed consent.
        The patient is conscious, coherent, cooperative, well oriented to time, place, person.
  • Pallor : Absent
  • Icterus : Absent
  • Cyanosis : Absent
  • Clubbing : Absent
  • Lymphadenopathy : Absent
  • Edema of feet : Absent
VITALS
 ( ON THE DAY OF ADMISSION ) : 4TH MAY
  • Temperature: 97 F
  • Pulse rate : 80 beats/min
  • Respiratory rate: 18/min
  • Blood pressure: 130/80 mm of Hg
  • SpO2 at room air: 97%
5th MAY
  • Temperature 98.6 F 
  • Pulse rate : 86 beats/min
  • Respiratory rate: 20/min
  • Blood pressure: 120/70 mm of Hg
  • SpO2 : 96% on 10 ltrs of Oxygen
6TH MAY
  • Temperature 98.4 F 
  • Pulse rate : 98 beats/min
  • Blood pressure: 110/70 mm of Hg
  • SpO2 : 98% on 10 ltrs of Oxygen
  • GRBS: 138 mg/dl
7TH MAY
  • Temperature 98.6 F 
  • Pulse rate : 90 beats/min
  • Blood pressure: 100/70 mm of Hg
  • SpO2 : 90% on 10 ltrs of Oxygen
  • GRBS: 203 mg/dl
8TH MAY
  • Temperature 98.6 F 
  • Pulse rate : 104 beats/min
  • SpO2 : 88% on 10 ltrs of Oxygen
SYSTEMIC EXAMINATION : 
  • CVS : S1 , S2 heard . No added murmurs, thrills 
  • Respiratory system: Trachea - Central , grade 2 dyspnea, no wheeze, normal vesicular breath sounds heard 
  • per abdomen : Central obesity, soft, non tender, liver & spleen not palpable
  • CNS: Intact
INVESTIGATIONS : 
OUTSIDE REPORTS
  • RBS: 342 mg/dl
  • LFT: Normal
  • RFT: Normal
  • CBP: Normal
  • ESR: 15
  • CRP: Negative
4TH MAY
  • Hb : 11.8 
  • TLC : 4600
  • Widal test : -ve
  • ESR: 15
  • TB : 0.9
  • DB: 0.5
  • RBS: 342 Mg/dl
  •  K+: 4.3
  • Na+: 141 
  • Ca+2: 9
  • Creatinine: 1.0
  • Albumin: +VE
  • D-DIMER: 250 ng/ml
  • Hb1ac: 6.8
  • Fbs: 165 mg/dl
ECG REPORT :  

PROVISIONAL DIAGNOSIS : 
- Viral pneumonia and Gastroenteritis due to COVID- 19 infection. 

TREATMENT : 
-ON 4 MAY : 
1. O2 inhalation 
2. Tab. Sporolac -Ds / TIS 
3.ORS - 1 packet in 1 lt of water, 200 ml after passing stool 
4.Tab . Pantop 40 mg /OD 
5.Syp . Grillinctus 10 ml/TID 
6.Tab . Paracetamol 65mg
7.BP , PR, SpO2 monitoring 
8.I/O charting 

-ON  5 MAY :
The above treatment is -continued with 
1 . Tab. Fabiflu 400 mg ( 5 tabs morning and 5 tabs at night) 
2. Tab Limcee 500 mg /OD 
3 . GRBS charting(7 a. m -1 p. m - 7 p. m ) 
4.Tab multivitamin /OD 

-FROM 6 MAY TO 8 MAY 
The above treatment is continued with -
1 . Inj. Dexamethasone 6mg/i.v./OD 
2 . Nebulization with Duolin,Budecort, Mucomist 

Despite all measures SpO2 levels decreased, patient's condition was not improving. Pulse was not recordable on day 5 of admission and ECG showed isoelectric line. Patient was declared dead. 
ECG :



IMMEDIATE CAUSE OF DEATH : 
-Cardiopulmonary arrest 
ANTECEDENT CAUSE OF DEATH :
- Severe ARDS ( secondary to COVID-19) 

Questions : 
1. What is the link between covid 19 and gastrointestinal symptoms? 
2. How do you differentiate stomach flu ( causing gastroenteritis ) from covid 19 ? 









 


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