43 YEAR OLD FEMALE WITH COVID PNEUMONIA

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Name: Sreshta J

Roll no: 48

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 a diagnosis and treatment plan.

Following is the view of my case :

Case admitted to COVID ICU

History was taken by

1. Dr V Praneeth sir PGY3 

2. Dr Susmitha ma'am PGY2

CASE PRESENTATION

A 43-year-old female has presented to the OPD on 11 May 2021 with the chief complaints of

• fever for 10 days
• positive rapid antigen test 1 week ago
• dry cough for 4 days

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 10 days ago when she developed a temperature and dry cough. They were insidious in onset. 

Three days later she took the Rapid Antigen Test which came back positive. 

Dry cough has increased over the last 4 days.

She came to the hospital when she developed Shortness of Breath and it was found to be grade 3 on admission.

PAST HISTORY :

• no h/o of hypertension 
• no h/o diabetes
• no h/o tuberculosis, asthma

PERSONAL HISTORY :

• married
• lost appetite
• takes mixed diet
• bowel movements are regular
• micturition is normal
• no known allergies
• no addictions

FAMILY HISTORY:

Nothing significant

TREATMENT HISTORY:

She has taken 2 doses of Inj. Remedesivir before admitting to our hospital.

GENERAL EXAMINATION:

Done after obtaining consent, in a well-lit room, in the presence of an attendant, with adequate exposure. The patient is conscious, coherent, cooperative, well-nourished, well -oriented to time, place, person.

No pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Generalised Lymphadenopathy or Pedal Edema.

VITALS at the time of admission:

• Temperature - 98.6 degrees Fahrenheit
• Pulse rate- 76 bpm
• BP- 100/70 mm Hg
• Respiratory rate- 43/min
• SpO2- 93% at 12 Lit of O2 

SYSTEMIC EXAMINATION:

1. CVS: S1 & S2 heard

2. Respiratory system: 

• Dyspnoea - present
• Adventitious sounds- Ronchi

3. Abdomen: Normal

4. CNS: Normal

INVESTIGATIONS:

1. COMPLETE BLOOD PICTURE:

• Hb- 11 gm%
• TC- 13,900
• DC- Neutrophils- 95, Lymphocytes- 2, Eosinophils- 1, Monocytes- 2, Basophils- 0
• D-Dimer- 920 ng/ml
• CRP- 2.4 mg/dl

2. LIVER FUNCTION TESTS:

• SGOT- 40 IU/L
• SGPT- 66 IU/L
• ACP- 91
• Protein- 3.3 gm%
• Albumin- 3.0 gm%
• A/G ratio- 1.27

3. RENAL FUNCTION TESTS:

• Blood urea- 31 mg/dl
• Serum creatinine- 0.7 mg/dl
• Uric acid- 2.0 mg/dl
• Ca+2- 9.8 mg/dl
• Phosphorous- 1.9 mg/dl
• Na+ - 142 mEq/lit
• K+ - 3.9 mEq/lit
• Cl- - 102 mEq/lit

ECG:

PROVISIONAL DIAGNOSIS:

SARS COVID - 19 Positive

TREATMENT PLAN  (given on 11 May 2021):

1. IVF 10 NS with optineuron at75 ml/hr
2. O2 inhalation to be maintained at >90%
3. Nebulization with Duolin and Budecort every 6 hours.
4. Inj Dexamethasone 8 mg IV OD
5. Inj Pan 40 mg IV OD
6. Tab MVT OD
7. Tab Limcee OD
8. Tab Augmentin 625 mg BD
9. GRBS 6th hourly
10. Tab Dolo 650 mg SOS
11. Temp. charting every 4th hourly
12. BP, RR, SpO2 monitoring hourly
13. Inj Celaxane 40 mg SC OD
14. Tab Sporolac 2 tabs PO TID
15. Syrup Grilinctus 15 ml PO BD

12 May 2021

VITALS:

• Temperature - 98 degrees Fahrenheit
• Pulse rate- 124 bpm
• BP- 100/60 mm Hg
• Respiratory rate- 34/min
• SpO2- 90% at 12 Lit of O2 

UPDATED TREATMENT PLAN:

1. IVF 20 NS with optineuron at75 ml/hr
2. O2 inhalation to be maintained at >90%
3. Nebulization with Duolin and Budecort every 6 hours.
4. Inj Dexamethasone 8 mg IV OD
5. Inj Pan 40 mg IV OD
6. Tab MVT OD
7. Tab Limcee OD
8. Tab Augmentin 625 mg BD
9. GRBS 6th hourly
10. Tab Dolo 650 mg SOS
11. Temp. charting every 4th hourly
12. BP, RR, SpO2 monitoring hourly
13. Inj Celaxane 40 mg SC OD
14. Tab Sporolac 2 tabs PO TID
15. Syrup Grilinctus 10 ml - 10 ml -10 ml 

10 pm: 3 episodes of loose stools since admission.

CPR NOTES:

10.30 pm 

• The patient collapsed and CPR was started, following the ACLS guidelines
• PR and BP not registered
• Inj Adrenaline was given through IV
• Chest compressions and breaths in the ratio of 30:2/cycle were given

10.35 pm

• PR and BP not registered
• Inj Adrenaline was given through IV
• Chest compressions and breaths in the ratio of 30:2/cycle were given

10.40 pm

• PR and BP not registered
• Inj Adrenaline was given through IV
• Chest compressions and breaths in the ratio of 30:2/cycle were given

10.45 pm

• PR and BP not registered
• Inj Adrenaline was given through IV
• Chest compressions and breaths in the ratio of 30:2/cycle were given

10.50 pm

• PR and BP not registered
• Inj Adrenaline was given through IV
• Chest compressions and breaths in the ratio of 30:2/cycle were given

The patient could not be revived and the ECG showed a flat line. The patient was declared dead at 10.51 pm. 

Immediate cause of death- Severe Hypoxia

Antecedent cause of death- COVID 19.

DEATH NOTES: 

Since admission, the patient had persistent breathlessness. Saturations on room air was 36%. She was diagnosed with covid-19 severe pneumonia. The patient was admitted to ICU and was administered oxygen therapy with non-invasive ventilation she was tolerating BiPAP well and SpO2 with FiO2 60% was 90% consistently. At 10:30 p.m. the patient suddenly collapsed and became unresponsive. CPR was started immediately and continued for 20 minutes but she could not be revived. The immediate cause of death is Severe Hypoxia. Antecedent cause of death- COVID 19.

ACKNOWLEDGEMENT:

I'd like to extend my sincere gratitude to Dr Rakesh Biswas sir (HOD, General Medicine) for providing me with this opportunity, as well as Dr Kranthi ma'am (Intern) for her supervision.