General medicine case discussion

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 ?