70 YEAR OLD MALE WITH FEVER, SHORTNESS OF BREATH AND COVID POSITIVE

 MEDICAL CASE DISCUSSION

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from 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-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

May 19, 2021

YOGITA AILANI

Roll no:149

CASE DISCUSSION

A 70 year old Male came to GM OPD with chief complaints of 

1. Fever since 14 days
2. Shortness of breath since 7 days 
3. Cough since 7 days
4. Generalized body pains since 7 days 

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 30 days back then he developed

• Fever which was insidious in onset and of intermittent type, not associated with chills/rigor, no aggrevating factors present but relieved with medication.
• Dry cough which was insidious in onset and has no aggrevating or relieving factors.
• Loss of appetite
• Generalised body pains

He was tested POSITIVE for SARS COV-2 on 20th of April 2021.

He was admitted to Hospital -1 and got treated for SARS COV-2.

Got tested again for SARS COV-2 on 1st May 2021 (in govt hospital) results were NEGETIVE

But the patient was still having symptoms 

So he got HRCT done in another hospital and was declared POSITIVE for SARS COV-2 by assessing HRCT.

The patient was in HOME ISOLATION as his saturation levels were normal.

From past 7 days he developed shortness of breath and it aggrevated on 18th May 2021 and the patient was admitted in the present Hospital.

PAST HISTORY

1. Patient is a k/c/o - Psoriosis since 15 years
2. k/c/o - DM type 2 since 4 years
3. k/c/o - HTN since 4 years
4. He got a HEART ATTACK 4 years back and underwent surgery for the same.

FAMILY HISTORY

His Son was also tested POSITIVE for SARS COV-2 on 20th April 2021.

He was in HOME ISOLATION and took the general medication.

Got tested again on 1st May 2021 and the results were NEGETIVE.

PERSONAL HISTORY

Diet                   - Mixed

Sleep                - Adequate

Appetite            - Decreased

Bowl & Bladder - Normal

Addictions         - Regular intake of alcohol (90ml) from 20 years

                          - Before used to consume Toddy for 10 years

SURGICAL HISTORY

CABG(coronary artery bypass graft) - 4 years back

GENERAL EXAMINATON

The patient was conscious, coherent and co-operative.

He is well oriented to time place and person.

Icterus                    - Absent

Pallor                      - Absent

Clubbing                 - Absent

Cynosis                   - Absent

Lymphadenopathy  - Absent

Edema                    - Absent

VITALS

18/05/2021

• temperature : afebrile
• pulse rate : 130bpm
• respiratiory rate : 32/min
• blood pressure : 110/70mmHg
• spo2 at room air : 87%

19/05/2021

• temperature : afebrile
• pulse rate : 110bpm
• blood pressure : 110/90mmHg
• spo2 : 95% at 4L of O2

20/05/2021

• temperature : afebrile
• pulse rate : 104bpm
• blood pressure : 110/70mmHg
• spo2 at room air : 92%
• spo2 : 96% at 10L of O2

21/05/2021

• temperature : afebrile
• pulse rate : 96bpm
• blood pressure : 110/70mmHg
• spo2 at room air : 92%
• spo2 : 98% at 2L of O2

22/05/2021

• temperature : afebrile
• pulse rate : 101bpm
• blood pressure : 120/70mmHg
• spo2 at room air : 77%
• spo2 : 98% at 10L of O2 NRM
• GRBS : 210mg/dl
• CT  severity score : 19/25

23/05/2021

• temperature : 99 degree F
• pulse rate : 115bpm
• respiratory rate : 22/min
• blood pressure : 120/80mmHg
• spo2 : 93% at 10L of O2 NRM
• GRBS : 152mg/dl

24/05/2021

• temperature : afebrile
• pulse rate : 124bpm
• respiratory rate : 24/min
• blood pressure : 130/80mmHg
• spo2 at room air : 69%
• spo2 : 91% at 12L of O2 NRM

25/05/2021

• temperature : afebrile
• pulse rate : 114bpm
• respiratory rate : 22/min
• blood pressure : 130/80mmHg
• spo2 : 90% at 10L of O2 NRM
• spo2 : 94% at 14L of O2 NRM

26/05/2021

• temperature : afebrile
• pulse rate : 103bpm
• respiratory rate : 22/min
• spo2 : 97% on NRM -10L of O2
• GRBS : 95mg/dl

27/05/2021

• temperature : afebrile 
• pulse rate : 130bpm,reg
• respiratory rate : BAE+, on NRBM
• SPO2 : 98% on NRBM at 15L of O2
• GRBS : 362mg/dl

28/05/2021

• temperature : afebrile
• pulse rate : 101bpm
• respiratory rate : 27/min
• SpO2 : 78% on Room Air
• SpO2 : 90% on BiPAP
• GRBS @8AM : 163 mg/dl
• CT severity score : 19/25 (17/5) 
• (CORADS-5) 
• SOB has reduced comparatively. 

29/05/2021

• temperature : afebrile
• pulse rate : 96bpm
• blood pressure : 110/70mmHg
• SpO2 : 92% with with 15L of O2. 
• GRBS @ 8 AM : 171mg/dl

30/05/2021

• temperature : afebrile
• pulse rate : 99bpm
• Blood pressure : 110/70mmHg
• SpO2 : 97% @ high flow O2
• GRBS @ 8AM : 80 mg/dl

31/05/2021

• temperature : afebrile
• pulse rate : 96bpm
• Blood pressure : 110/70mmHg
• SpO2 : 92% with NRBM with 15L of O2
• GRBS @ 8AM : 80 mg/dl

01/06/2021

• temperature : afebrile
• pulse rate : 100bpm
• Blood pressure : 110/70mmHg
• SpO2 : 99% with NRBM with 15L of O2
• GRBS @ 7AM : 70 mg/dl                    

SYSTEMIC EXAMINATION (during the time of admission)

RS   - Normal vesicular breath sounds heard

CVS - S1 and S2 heard

PA    - Soft and non tender

CNS - intact

LOCAL EXAMINATION

lesions present on both legs as patient is a k/c/o Psoriasis 

                  LEFT LEG        

RIGHT LEG

                                                                 

       

                                        

INVESTIGATIONS

Reports from the present Hospital

Date:18/05/2021

COMPLETE BLOOD PICTURE

ABG

FASTING BLOOD SUGAR

C-REACTIVE PROTEIN(CRP)

D-DIMER

ERYTHROCYTE SEDIMENTTION RATE(ESR)

LDH

LIVER FUNCTION TEST(LFT)

RENAL FUNCTION TEST(RFT)

ECG

Date: 19/05/2021

CT CHEST & ABDOMEN

ECG

Date: 24/05/2021

ECG

DAY WISE PROGRESS OF PATIENT:

PROVISIONAL DIAGNOSIS

Viral Pneumonia Secondary to COVID-19

TREATMENT

18/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.T.P.R . BP charting +SpO2

10.Inform SOS

11.GRBS checking 6th hourly(8AM-1PM-8PM-2AM) 

12.Tab.Glimepiride 1mg/po/OD(8AM-before breakfast) 

13.Tab.Metformin 500mg po/BD(9AM & 9PM) 

14.Tab.Telma AM 40/5/po/OD(8 AM) 

15.4 Egg whites/day

16.Inj CLEXANE 40 mg s/c BD

17.Inj.Dexamethasone 8mg/IV/OD

19/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.T.P.R . BP charting +SpO2

10.GRBS checking 6th hourly(8AM-1PM-8PM-2AM) 

11.Tab.Telma AM 40/5/po/OD(8 AM) 

12.Inj CLEXANE 40 mg s/c BD

13.Inj.Dexamethasone 8mg/IV/OD

14.Tab.Ecosprin-AV-180mg/po/OD

20/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Inj.Dexamethasone 8mg/IV/OD

12.Tab Ecosprin-AV-180mg/po/OD

21/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Inj.Dexamethasone 8mg/IV/OD

12.Tab Ecosprin-AV-180mg/po/OD

22/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Inj.Dexamethasone 8mg/IV/OD

12.Tab Ecosprin-AV-180mg/po/OD

23/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Inj.Dexamethasone 8mg/IV/OD

12.Tab Ecosprin-AV-180mg/po/OD

13.GRBS-70 profile monitoring

 (before breakfast, 2 hrs after breakfast, Before lunch, 2 hrs after lunch, before dinner, 2hrs after dinner) 

14.Tab.Glimepiride 1mg/BD

15.Inj.HAI s/c, sos TID

24/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Inj.Dexamethasone 8mg/IV/OD

12.Tab Ecosprin-AV-180mg/po/OD

13.GRBS-70 profile monitoring

14.Tab.Glimepiride 1mg/BD

15.Inj.HAI s/c, sos TID

25/05/2021 

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Augmentin 625/po/BD

4.Tab.Pan 40/po/OD

5.Tab.Dolo 650/po/sos

6.Tab.Limcee/po/OD

7.Tab.MVT/po/OD

8.Nebulisation:Duolin, budecort, mucomist-6th hourly

9.Tab.Telma 40/5mg/po/OD

10.Inj CLEXANE 40 mg s/c BD

11.Tab Ecosprin-AV-180mg/po/OD

12.GRBS-70 profile monitoring

13.Tab.Glimepiride 1mg/BD

14.Inj.HAI s/c, on sliding scale(sos) 

15.Tab.Metformin 500mg/po/BD

16.Syp.Ascoryl 10ml QID

(Inj.Dexamethasone stopped) 

26/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Pan 40/po/OD

4.Tab.Dolo 650/po/sos

5.Tab.Limcee/po/OD

6.Tab.MVT/po/OD

7.Nebulisation:Duolin, budecort, mucomist-6th hourly.

8Tab.Telma 40/5mg/po/OD

9.Inj CLEXANE 40 mg s/c BD

10.Tab Ecosprin-AV-180mg/po/OD

11.GRBS-70 profile monitoring

12.Tab.Glimepiride 1mg/BD

13.Inj.HAI s/c, on sliding scale(sos)

14.Tab.Metformin 500mg/po/BD

15.Syp.Ascoryl 10ml QID

(Tab.Augmentin stopped) 

27/05/2021

1.O2 Inhalation to maintain spO2

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Pan 40/po/OD

4.Tab.Dolo 650/po/sos

5.Tab.Limcee/po/OD

6.Tab.MVT/po/OD

7.Nebulisation:Duolin, budecort, mucomist-6th hourly

8.Tab.Telma 40/5mg/po/OD

9.Inj CLEXANE 40 mg s/c BD

10.Tab Ecosprin-AV-180mg/po/OD

11.GRBS-70 profile monitoring

12.Tab.Glimepiride 1mg/BD

13.Inj.HAI s/c, on sliding scale(sos) 

14.Tab.Metformin 500mg/po/BD

15.Syp.Ascoryl 10ml QID1

16.Intermittent BiPAP

28/05/2021

1.Continuous BiPAP

2.IVF 20NS with optineuron@75ml/hr

3.Tab.Pan 40/po/OD

4.Tab.Dolo 650/po/sos

5.Tab.Limcee/po/OD

6.Tab.MVT/po/OD

7.Nebulisation:Duolin,mucomist-8th hourly;Budecort-12th hourly

8.Tab.Telma 40/5mg/po/OD

9.Inj CLEXANE 40 mg s/c BD

10.Tab Ecosprin-AV-180mg/po/OD

11.Tab.Glimepiride 2mg/po/BD

12.Metformin 500mg/po/BD

13.Inj.HAI s/c,on sliding scale (sos)TID

14.GRBS monitoring (70 profile) -6th hourly

15.Monitor vitals

16.Syp.Ascoryl 10ml QID

29/05/2021

1. Inj clexane 40mg SC bd (D11)

2. Intermittent BiPAP

3. Tab ecospirin Av-150/40 po/od  

4. tab metformin 500 mg po/od 

5. Tab pantop 40mg po od

6. Tab limcee 500mg po od 

7. Tab zincovit po od

8. tab glimeperide 2mg po/bd

9. Tab dolo 650mg po sos 

10. Nebulisation with budecort 8th hourly 

11. Syp ascoril 15ml po hs 

12. Grbs monitoring-6th hrly

13. Spirometry 

14. Prone positioning 

 15.Monitor vitals

30/05/2021

1. Inj clexane 40mg SC bd (D12) 

2. Intermittent BiPAP

3. Tab ecospirin Av-150/40 po/od  

4. tab metformin 500 mg po/od 

5. Tab pantop 40mg po od

6. Tab limcee 500mg po od 

7. Tab zincovit po od

8. tab glimeperide 2mg po/bd

9. Tab dolo 650mg po sos 

10.Tab.telma 40 mg po OD

11.Nebulisation with budecort 8th hourly 

12. Syp ascoril 15ml po hs 

13. Grbs monitoring-6th hrly

14.inj HAI s/c according to sliding scale 

15.Monitor vitals and inform sos

31/05/2021

1. Inj clexane 40mg SC bd (D13) 

2. Intermittent BiPAP

3. Tab ecospirin Av-150/40 po/od  

4. tab metformin 500 mg po/od 

5. Tab pantop 40mg po od

6. Tab limcee 500mg po od 

7. Tab zincovit po od

8. tab glimeperide 2mg po/bd

9. Tab dolo 650mg po sos 

10.Tab.telma 40 mg po OD

11.Nebulisation with budecort 8th hourly 

12. Syp ascoril 15ml po hs 

13. Grbs monitoring-6th hrly

14.spirometry and prone positioning

15.Monitor vitals and inform sos

01/06/2021 

1. Inj clexane 40mg SC bd (D11)

2. Intermittent BiPAP

3. Tab ecospirin Av-150/40 po/od  

4. tab metformin 500 mg po/od 

5. Tab pantop 40mg po od

6. Tab limcee 500mg po od 

7. Tab zincovit po od

8. tab glimeperide 2mg po/bd

9. Tab dolo 650mg po sos 

10. Nebulisation with budecort 8th hourly 

11. Syp ascoril 15ml po hs 

12. Grbs monitoring-6th hrly

13. Spirometry 

14. Prone positioning 

 15.Monitor vitals

I would like to thank Rakesh Biswas Sir for providing us this opportunity.

Thank you Durga Krishna Sir and Vilasith Sir for guiding me.