Case discussion on viral pneumonia secondary to COVID -19

 

May 23, 2021

CHENNAMADHAVUNI DIVYA, 8th semester

Roll number-21

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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.

Following is the view of my case:

Date of admission :5-5-2021   

Chief complaints :

A 38 year old male patient has come to the opd with the chief complaints of     

• Fever : since 4 days
• Shortness of breath :since 1 day
• Loss of taste sensation :since 4 days
• Generalized weakness :since 4 days     

History of present illness :

Patient was apparently  asymptomatic 4 days back and then he developed ,

Fever ,which was insidious in onset ,high grade ,continuous in nature and not associated with chills and rigors.

he had loss of taste sensation.

he had generalized weakness, which was insidious in onset, gradually progressing in nature.

he developed shortness of breath GRADE = 3 of( NYHA classification) a day ago which was, insidious in onset and gradually progressing 

he also had a history of loose stools for a day

he had no complaints of: cough, loss of smell, vomitings , nausea ,chest pain

History of past illness :

Not a known case of Diabetes ,hypertension ,asthma ,tuberculosis ,epilepsy ,CVA

No significant surgical history

No known allergic history

Personal history :

Diet - mixed

Appetite - decreased

sleep - adequate

Bowel and Bladder movements - regular

Addictions - drinks wine on a regular basis,

             chews tobacco

Drug history : 

Insignificant

Family history :

No significant family history

General examination :

Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person 

at the time of examination

he is examined in a well lit room, with consent taken

he is moderately built and well nourished

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Edema - absent

Vitals : on the day of admission (5/5/2021)

Temperature -98 degrees F

Pulse rate - 96 bpm

Respiratory rate - 20 cpm

Blood pressure - 110/70 mmHg

SpO2 -89% on Room air

GRBS - 110 mg/dl

Day 2 -6/5/2021 :

Pulse rate - 96 bpm

Blood pressure - 140/100 mmHg

SpO2 -89% on room air

        96% on 5 liters of O2

GRBS - 111 mg/dl

 Day 3 -7/5/2021

Temperature - 98 degrees F

Pulse rate - 84 bpm

Blood pressure - 100/70 mmHg

SpO2 -96% on room air

GRBS - 179 mg/dl

Day 4 - 8/5/2021 (on the day of discharge)

Temperature - 98 degree F

Pulse rate -88 bpm

Blood pressure -120/70 mmHg

SpO2 - 96% on room air

Systemic examination :

CVS : S1 and S2 heart sounds heard

      NO murmurs and thrills

RESPIRATORY SYSTEM : Bilateral air entry present                            position of trachea - centrall

                        Vesicular breathsounds heard

CNS : intact

ABDOMEN : Soft and non tender

              No palpable masses

              Bowel sounds heard 

              NO organomegaly

Investigations :

LFT:

Total bilirubin -1.98 mg/dl

Direct bilirubin -0.61 mg/dl

AST -61 IU/L

ALT -41 IU/L

ALP -178 IU/L

Total proteins - 6.4 gm/dl

Albumin -3.6 gm/dl

A/G ratio -1.29

RFT:

Urea - 29 mg/dl

Creatinine -0.4 mg/dl

Uric acid -7.6 mg/dl

Calcium - 9.4 mg/dl

Sodium - 137 mEq/L

Potassium -3.8 mEq/L

Chloride -97 mEq/L

D-Dimer: 100 ng/dl

Serum LDH: 595 units/lit

CRP: 2.4 mg/dl (positive)

Ferritin - >1500 ng/ml

CXR

Provisional Diagnosis :

 Viral pneumonia secondary to COVID-19 

Treatment :

 From 6/5/2021 to 18/5/17 : 

• O2 supplementation
• Nebulisation with Budecort ,Duolin- 8th hourly, mucomist - 12th hourly 
• Syrup. Grilinctus -10ml/ TID
• Tab. PARACETAMOL 650 mg/PO/OD
• Tab. PANTOP 40 mg/PO/OD
• Temperature charting 6th hourly
• BP, PR, SpO2 monitoring
• IVF- 1 unit NS,1 unit DNS with Optineuron at the rate of 75 ml/hr
• INJ. DEXAMETHASONE 6 mg/IV/OD
• INJ. CLEXANE 40 mg/SC/OD

The patient was advised to discharge on 18/5/2021 ,3.00pm as his condition was stable, with SpO2- 96% on room air and is asked to take the following medications at home,

• Tab. MVT OD for 2 weeks
• Tab. LIMCEE BD for 2 weeks
• Tab. PAN TOP 40 mg OD,30 min before having breakfast
• Tab. PARACETAMOL 650 mg SOS
• Review SOS in case of High-grade fever, breathlessness.      

 I would like to thank Dr.Rakesh Biswas sir for this oppurtunity and Dr.charan sir for the guidance

   

  Questions:

1. Why are his ferritin levels so high? Is that related      to his ,being infected with COVID-19 condition?

2.why is optineuron given to COVID-19 patients? Is  

    vitamin-B12 deficiency a risk factor for covid?

3.His GRBS shooted to 179 mg/dl, is that because of      the COVID-19 infection?