COVID CASE DISCUSSION - 45 year female

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A 45 year old female presented with complaints of fever, shortness of breathe, loose stools.

K.Lasya Mithra, 8th semester

Roll No: 50

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 plan.

CASE:

 

A 45 yr old female who is cook in a school presented to hospital with chief complaints of

• Fever - 1 week
• Shortness of breathe - 4 days
• loose stools - from morning

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 week back then she developed 

• Fever which is sudden in onset, high grade, with no associated chills and rigors. She was tested COVID positive and also gives a contact history with her husband who was COVID positive.

• She developed of shortness of breathe from 4 days which was insidious in onset initially grade-2 ( on exertion) and gradually progressed to grade-4 (on rest). It was not associated with chest pain, palpitations, sweating.

• Patient complained of loose stools since morning and had 2 episodes. 

                      First episode- greenish in colour, watery consistency

                   second episode- dark, tar coloured, watery consistency

• complaint of burning micturition from 5- 6 yrs which is intermittent and was on medication.
• No history of vomiting.

PAST HISTORY:

• Known case of hypothyroidism from 10 years and on medication Thyronorm- 150 mcg, OD.
• No history of diabetes, hypertension, asthma, epilepsy, TB, CVD.

PERSONAL HISTORY: 

• Appetite: Normal
• Diet: Mixed
• Bowel and Bladder: Burning micturition - from 5-6 yrs, which is intermittent and  relived temporarily on medication. Patient also complained of constipation.
• Sleep: adequate
• Addictions: absent
• no history of drug and food allergies.

FAMILY HISTORY:

• Husband was tested COVID-19 positive 
• No history of diabetes, hypertension, thyroid, CVD in family.

GENERAL EXAMINATION:

• Patient is conscious, coherent and cooperative
• moderately built and nourished
• pallor: absent
• Icterus: absent
• Cyanosis: absent
• Clubbing: absent
• Edema: absent
• Lymphadenopathy: absent

• Vitals: ( on presentation)
• pulse rate: 120 bpm
• Blood pressure: 100/60 mm Hg
• Temperature: febrile
• respiratory rate: 35 cycles/min
• spO2: 78% at RA

INVESTIGATIONS:

CBP:

• Hemoglobin                  :   7.4 gm/dl
• TLC                              :   9,900 cells/cumm
• Platelets                        :   2.43 lakh
• PCV                              :   24.5

CRP :  Positive, 2.4 mg/dl

ESR : 80

D- DIMER : 1520 ng/ml

LDH : 481 IU/L

ABG :

• pH              :  7.14
• pCO2          : 37.2
  
• pO2            :  59.9
• HCO3         : 23.2
• St.HCO3     : 23.7
• BEB            : - 0.6
• BEecf          :- 0.7
• TCO2          : 49.7
• O2 sat          : 80.7
• O2 count     :  9.1

RFT:

• Urea                   :  15 mg/dl

• Creatinine          :  1.1 mg/dl
• Uric acid            :  2.5 mg/dl
  
• Calcium             :  9.6 mg/dl
• Phosphorus        :  4.0 mg/dl
• Sodium              :  138 mEq/L
• Potassium          :  4.0 mEq/L
• Chloride             : 104 mEq/L

 THYROID PROFILE:

• T3      : 0.66  ng/dl
• T4      : 15.04 ng/dl
• TSH   : 0.03 mIU/L

 CUE:

HRCT :

• CORADS - 5
• CT Severity - 23/25

 DIAGNOSIS:

Viral pneumonia secondary COVID - 19 and known case of hypothyroidism. 

TREATMENT:

02-05-21 ( On day of admission - day 4 of symptoms)

• O2 inhalation to maintain spO2 > 90%
• Nebulisation with BUDECORT - 8th hourly
• Syp. ASCORYL - 10ml, TID
• Tab. PCM - 650 mg
• BP, PR, spO2 - monitor hrly
• Foleys catheterization
• I/O Charting ( urine output)
• Tab. PANTOP- 40 mg, OD 
• Inj. DEXAMETHASONE - 8mg, IV, OD
• Tab. THYRONORM - 150 mcg, PO, OD 

03-05-21 (day 5 of symptoms)

Vitals :

• Temperature: afebrile 
•  Pulse rate: 80 bpm
• BP : 110/70 mm Hg
• spO2 : 96% on 10 lit of O2

Treatment: 

• O2 inhalation to maintain spO2 > 90%
• Nebulisation with BUDECORT - 8th hourly
• Syp. ASCORYL - 10ml, TID
• Tab. PCM - 650 mg
• BP, PR, spO2 - monitor hrly
• I/O Charting
• Tab. PANTOP- 40 mg, OD 
• Inj. DEXAMETHASONE - 8mg, IV, OD
• Tab. THYRONORM - 150 mcg, PO, OD 
• Inj. CLEXANE - 0.4 cc, OD

04-05-21( day 6 of symptoms)

 

Investigations:

• CBP :
• Hemoglobin                 : 7.6 gm/dl
• TLC                             :  12,900 cells/ cumm
• Platelets                       :  2.76 lakh
• Reticulocyte count       : 0.6
• ESR : 85

Vitals:

• Temperature: 98.6 F 
•  Pulse rate: 78 bpm
• BP : 100/60 mm Hg
• spO2 : 94% on 14 lit of O2
• respiratory rate: 50 cpm

Treatment: 

• O2 inhalation to maintain spO2 > 90%
• Nebulisation with BUDECORT - 8th hourly
• Syp. ASCORYL - 10ml, TID
• Tab. PCM - 650 mg
• BP, PR, spO2 - monitor hrly
• I/O Charting
• Tab. PANTOP- 40 mg, OD 
• Inj. DEXAMETHASONE - 8mg, IV, OD
• Tab. THYRONORM - 150 mcg, PO, OD 
• Inj. CLEXANE - 0.4 cc, OD
• Inj. TRANEXA- 500 mg, slow IV stat

05-05-21( day 7 of symptoms)

Vitals:

• Temperature: 98.6 F 
•  Pulse rate: 96 bpm
• BP : 120/70 mm Hg
• spO2 : 95% 
• respiratory rate: 25 cpm

Treatment: 

• O2 inhalation to maintain spO2 > 90%
• Nebulisation with BUDECORT - 8th hourly
• Syp. ASCORYL - 10ml, TID
• Tab. PCM - 650 mg, PO
• BP, PR, spO2 - monitor hrly
• I/O Charting
• Tab. PANTOP- 40 mg, OD 
• Inj. DEXAMETHASONE - 8mg, IV, OD
• Tab. THYRONORM - 125 mcg, PO, OD 

06-05-21( day 8 of symptoms)

Vitals:

• Temperature: 98.6 F 
•  Pulse rate: 90 bpm
• BP : 100/70 mm Hg
• spO2 : 94% 

Treatment: 

• O2 inhalation to maintain spO2 > 90%
• Nebulisation with BUDECORT - 8th hourly
• Syp. ASCORYL - 10ml, TID
• Tab. PCM - 650 mg , PO
• BP, PR, spO2 - monitor hrly
• I/O Charting 
• Tab. PANTOP- 40 mg, OD 
• Inj. DEXAMETHASONE - 8mg, IV, OD
• Tab. THYRONORM - 125 mcg, PO, OD 
• Inj. TRANEXA- 500 mg, slow IV stat

07-05-21( day 9 of symptoms)

Vitals:

• Temperature: 98.6 F 
•  Pulse rate: 106 bpm
• BP : 90/70 mm Hg
• spO2 : 98% on 10 lit of O2

Treatment: 

• O2 inhalation to maintain spO2 > 90%
• Nebulisation with BUDECORT - 8th hourly
• Syp. ASCORYL - 10ml, TID
• Tab. PCM - 650 mg
• BP, PR, spO2 - monitor hrly
• I/O Charting 
• Tab. PANTOP- 40 mg, PO, OD 
• Inj. DEXAMETHASONE - 8mg, IV, OD
• Tab. THYRONORM - 125 mcg, PO, OD 
• IV Fluids- NS- 75 ml/hr

08-05-21( day 10 of symptoms)

chest x- ray was taken

Vitals:

• Temperature: 98.6 F 
•  Pulse rate: 112 bpm
• BP : 100/60 mm Hg
• spO2 : 98% on 10 lit of O2

Treatment: 

• O2 inhalation to maintain spO2 > 90%
• Nebulisation with BUDECORT - 8th hourly
• Syp. ASCORYL - 10ml, TID
• Tab. PCM - 650 mg
• BP, PR, spO2 - monitor hrly
• I/O Charting
• Tab. PANTOP- 40 mg, OD 
• Inj. DEXAMETHASONE - 8mg, IV, OD
• Tab. THYRONORM - 125 mcg, PO, OD 
• IV Fluids - NS- 75ml/hr

09-05-21(day 11 of symptoms)

worsening of symptoms.

Vitals:

• Temperature: 98.6 F 
•  Pulse rate: 128 bpm
• BP : 100/60 mm Hg
• spO2 : 74% on 15 lit of O2, on venturi mask

Treatment: 

• O2 inhalation to maintain spO2 > 90%
• Nebulisation with BUDECORT and DUOLIN- 8th hourly
• Syp. ASCORYL - 10ml, TID
• Tab. PCM - 650 mg
• BP, PR, spO2 - monitor hrly
• I/O Charting
• Tab. PANTOP- 40 mg, OD 
• Inj. DEXAMETHASONE - 8mg, IV, OD
• Tab. THYRONORM - 125 mcg, PO, OD 
• Inj. CLEXANE - 40 mg, BD
• IV Fluids - NS - 75ml/hr

10-05-21( day 12 of symptoms)

8 :00 am

Vitals:

• Temperature: 98.6 F 
•  Pulse rate: 120 bpm
• BP : 100/60 mm Hg
• spO2 : < 80%  on 16 lit of O2 , started CPAP with 100% FiO2

Treatment: 

• O2 inhalation to maintain spO2 > 90%
• Nebulisation with BUDECORT and DUOLIN - 8th hourly
• Syp. ASCORYL - 10ml, PO, TID
• Tab. PCM - 650 mg, PO
• BP, PR, spO2 - monitor hrly
• I/O Charting 
• Tab. PANTOP- 40 mg, OD 
• Inj. DEXAMETHASONE - 8mg, IV, OD
• Tab. THYRONORM - 125 mcg, PO, OD 
• Inj. CLEXANE - 40 mg, OD
• IV Fluids- NS- 75ml/hr

12:30 pm

• Pulse rate: 136 bpm
• respiratory rate: 56 cpm
• BP: 110/70mm Hg
• spO2: 87% with CPAP and 16 lit of O2

4:40 pm

• Pulse rate: 120 bpm
• respiratory rate: 50 cpm
• BP: 110/70mm Hg
• spO2: 95% with CPAP and 16 lit of O2

Due to worsening of symptoms ECG was taken

 

There occurred gradually deterioration of symptoms on midnight of this day( 10-05-21) i.e patient was struggling to breathe inspite of all efforts (saturation started dropping even on 100% FiO2 ) . Patient became unresponsive and expired on 11-05-21 at 6:25 AM.

I would like to thank Dr. Rakesh Biswas sir ( H.O.D, General Medicine) for giving me this opportunity and thank you Dr. Vamshi Sir (P.G, General Medicine) for the guidance.