55 year old female with viral pneumonia secondary to COVID-19

 June 12th 2021

Student Name- D.Vineesha Chowdary 

2017 Batch

Roll no.- 24

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. 


A 55 year old female with viral pneumonia secondary to COVID-19


Following is the view of my case:


CHIEF COMPLAINTS:


A 55 yr old woman presented to the OPD on 9/05/21 with chief complaints of:

  • Myalgia since 1 week
  • Fever since 3 days
  • Shortness of breath since 3 days.
HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic until 7 days ago when she developed-

-Myalgia 

-Fever since 3 days which was insidious in onset, intermittent in nature, not associated with chills and rigour.

-She developed SOB 3 days ago, insidious in onset and gradual in progression.

-No complaints of chest pain, vomiting.

-No loss of smell and taste.


PAST HISTORY:

-Patient is a k/c/o Type 2 DM since 2 years and is on regular medications.

-H/O Kidney surgery on the left side for renal calculi.

-H/O of hysterectomy 10 years back.

FAMILY HISTORY:

-No history of similar complaints in the family.

-No history of DM, TB, Stroke, Asthma, or any other hereditary diseases in the family.


DRUG HISTORY:

-Medication for type 2 DM.

PERSONAL HISTORY:

Appetite: Normal
Diet: Mixed
Bowel movements: Regular
Bladder movements: Normal 
No known allergies
No addictions

GENERAL EXAMINATION:


The patient is examined in a well lit room with informed consent.
The patient is conscious, coherent and cooperative and is well oriented to time, place and person.
He is moderately built and well nourished.
Pallor: Absent
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent 
Lymphadenopathy: Absent 
Edema: Absent 

VITALS:

On 08/5/21 (At the time of admission):
Temperature- Afebrile
Heart Rate- 105 BPM
Blood Pressure- 110/70 mm of Hg
SPO2- 83% at room air

On 09/5/21(morning):
Temperature- 98.2 F
Heart Rate- 84 BPM
Blood pressure- 110/70 mm of Hg
SPO2- 92% at room air
GRBS- 155 mg/dl 

On 09/5/21(evening):
Temperature- Afebrile
Heart Rate- 88BPM
Blood Pressure- 120/80 mm of Hg
SPO2- 98% at 10L of O2

On 10/5/21:
Temperature- 97.4F
Heart Rate- 102 BPM
Blood Pressure- 110/70 mm of Hg
SPO2- 98% at 16L of O2

On 11/5/21:
Temperature- 97.4F
Heart Rate- 92BPM
Blood Pressure- 160/100 mm of Hg
SPO2- 92% at 16L of O2
GRBS- 232 mg/dl 

On 12/5/21:
Temperature- Afebrile
Heart Rate- 86 BPM
Blood Pressure- 130/90 mm of Hg
SPO2- 90-96% at 15L of O2 
GRBS- 193 mg/dl

On 13/5/21:
Temperature- 97.4F
Heart Rate- 84 BPM
Blood Pressure- 110/70 mm of Hg
SPO2- 98% on 8L of O2
GRBS- 193 mg/dl 

On 14/5/21:
Temperature- Afebrile
Heart Rate- 84 BPM
SPO2- 85-90% at 15L of O2 

SYSTEMIC EXAMINATION:

CVS SYSTEM: S1,S2 heard
No added thrills, no murmurs

RESPIRATORY SYSTEM: 
Dyspnea: SOB
Wheeze: Absent
Position of trachea: Central
Breath sounds: Vesicular breath sounds heard
Adventitious sounds: Not heard

PER ABDOMEN:
Soft, non tender, no organomegaly 

CNS:
Intact


INVESTIGATIONS:

1)Fasting Blood Sugar




2)Post Lunch Blood sugar




3)CBP




4)D-DIMER




5)LDH


6)LFT




7)RFT




8)CRP




9)ECG




10)Additional investigations




PROVISIONAL DIAGNOSIS:

Viral Pneumonia secondary to COVID-19 and DM.

HCRT shows CORADS 5 with CT severity 17/25

TREATMENT: 

(On 9/5/21):

Rx-

- O2 inhalation to maintain SpO2 > 90% 

-T.PCM 650mg P/O SOS

- Duolin, Budecort nebulisation every 8 hours

- GRBS every 8 hours

- Monitor PR, BD, SpO2 every hour

-Tab. GLIZID-M  80/500mg BD


(On 10/5/21):

Rx-

- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)

- Inj Clexane 40mg SC OD

- Inj Pantop 40mg IV/BD

- IVF -20NS at 75ml/hour

- Tab Glizid 80/500mg PO BD

- Duolin, Budecort nebulisation every 6 hours

- GRBS every 8 hours

- Temp charting 4 hourly

- Monitor PR, BD, SpO2 every hour

- Tab Oseltamivir 75mg BD

- Encourage oral fluids

-Head end elevation

-Tab Lime PO OD

-Tab Dolo 650mg PO SOS

- Temp Charting every 4 hours


(On 11/5/21):

Rx-

- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)

- Inj Clexane 40mg SC OD

- Inj Pantop 40mg IV/BD

- IVF -20NS at 75ml/hour

- Tab Glizid 80/500mg PO BD

- Duolin, Budecort nebulisation every 6 hours

- GRBS every 8 hours

- Temp charting 4 hourly

- Monitor PR, BD, SpO2 every hour

- Tab Clinidipine 10 mg OD

- Encourage oral fluids

-Head end elevation

-Tab Lime PO OD

-Tab Dolo 650mg PO SOS

- Temp Charting every 4 hours

-Inj. Dexamethasone 8 mg IV/OD


(On 12/5/21):

Rx-

- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)

- Inj Clexane 40mg SC OD

- Inj Pantop 40mg IV/BD

- IVF -20NS at 75ml/hour

- Tab Metformin SR 750mg PO BD

- Duolin, Budecort nebulisation every 6 hours

- GRBS every 8 hours

- Temp charting 4 hourly

- Monitor PR, BD, SpO2 every hour

- Tab Clinidipine 10 mg OD

- Encourage oral fluids

-Head end elevation

-Tab Lime PO OD

- Temp Charting every 4 hours

-Inj. Dexamethasone 8 mg IV/OD

-Tab MVT PO OD

-Intermittent CPAP

(On 13/5/21):

Rx-

- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)

- Inj Clexane 40mg SC OD

- Inj Pantop 40mg IV/BD

- IVF -20NS at 75ml/hour

- Tab Metformin SR 750mg PO BD

- Duolin, Budecort nebulisation every 6 hours

- GRBS every 8 hours

- Temp charting 4 hourly

- Monitor PR, BD, SpO2 every hour

- Tab Clinidipine 10 mg OD

- Encourage oral fluids

-Head end elevation

-Tab Lime PO OD

- Temp Charting every 4 hours

-Inj. Dexamethasone 8 mg IV/OD

-Tab MVT PO OD

-Intermittent CPAP

(On 14/5/21):

Rx-

- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)

- Inj Clexane 40mg SC OD

- Inj Pantop 40mg IV/BD

- IVF -20NS with 1 amp of optineuron

- Tab Metformin SR 750mg PO BD

- Duolin, Budecort nebulisation every 6 hours

- GRBS every 8 hours

- Temp charting 4 hourly

- Monitor PR, BD, SpO2 every hour

- Tab Clinidipine 10 mg OD

- Encourage oral fluids

-Head end elevation

-Tab Lime PO OD

- Temp Charting every 4 hours

-Inj. Dexamethasone 8 mg IV/OD

-Tab MVT PO OD

-Intermittent CPAP

QUESTIONS:

1)Why was the patient switched to metformin from sulfonylureas?

2)What was the rationale behind giving corticosteroids to this patient?



Under the guidance of Dr. Kranthi mam.

I thank Dr. Rakesh Biswas sir for this opportunity that provides a better learning to students like us.






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