A 52 YEAR OLD FEMALE WITH FEVER, SHORTNESS OF BREATH AND DRY COUGH

RACHANA GANGULA

MBBS 8TH SEMESTER

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.

CASE: 

A 52 year old female patient came to the ward on the 19th of May with chief complaints of 

• FEVER since 10 days
• DRY COUGH since 4 days
• SHORTNESS OF BREATH since 3 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 days back when she developed

 -Fever which was insidious in onset, intermittent in nature, not associated with chills and rigors. 
 -Dry cough which was insidious in onset, intermittent in nature, with no diurnal or positional variations and no associated aggravating or relieving factors were noted.

 -She developed Grade 2 shortness of breath (NYHA CLASSIFICATION) three days ago, insidious in onset and gradually progressed to Grade 3 shortness of breath

  -No complaints of vomiting, chest pain, loss of smell and taste.

PAST HISTORY

K/C/O Hypertension, duration unknown, on medication

K/C/O Diabetes Mellitus, duration unknown, on medication

PERSONAL HISTORY

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder movements: regular

Addictions: none

DRUG HISTORY

Takes Tab.Amlodipine

Takes Oral Hypoglycemic drugs (unknown)

Took Remdesivir and has undergone plasma infusion with 2U of plasma before arriving to hospital.

FAMILY HISTORY

No history of similar complaints in the family.

No history of Diabetes, Tuberculosis, Stroke, Asthma, any other hereditary diseases in the family.

GENERAL EXAMINATION: 

The patient is examined in a well lit room, with informed consent

The patient is conscious, coherent, cooperative, is well oriented to time, place, person.

She is moderately built and nourished.

Pallor : absent

Icterus : absent

Cyanosis : absent

Clubbing : absent

Lymphadenopathy : absent

Edema : absent

Dehydration: moderate

VITALS:

 On the day of admission-19/05/2021; 7:15 PM

 Temperature-Febrile

 Heart rate-109 beats/min

 Blood pressure-100/60 mmHg

 Respiratory rate- 42 cycles/min

 SPO2- 79% at room air

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard

         No added thrills, murmurs

RESPIRATORY SYSTEM:   Trachea is central in position

                                               Dyspnoea present

                                               Wheeze present

                                               Tubular breath sounds heard

                                             

PER ABDOMEN: soft, non tender, no organomegaly

CNS: intact

INVESTIGATIONS 

GRBS-135 mg/dl

COVID RT-PCR +ve 

CT score- 12/25

~ no further investigation data obtained ~

PROVISIONAL DIAGNOSIS 

Moderate to Severe Viral Pneumonia secondary to COVID-19 

TREATMENT REGIMEN                                             

1. Inj. Dexamethasone 8mg IV TID
2. Inj. Pan 40mg IV OD
3. Inj. CLEXANE SC OD
4. GRBS charting 6th hourly 
5. Inj HAI SC according to sliding scale
6. Tab. AMLONG p/o OD
7. TEMP and BP checking 4th hourly
8. INTERMITTENT BIPAP 

Despite all the above measures, at 10:05 pm on 19/5/21, within 3 hours of hospitalization, the patient was declared dead. 

Patient was put on BIPAP(ventillator) and was tolerating SpO2 92-94% on FiO2 90% and PEEP 5-7mmH2O. At 9:45 pm, she suddenly developed seizure with loss of consciousness. Patient was immediately taken off BIPAP and put on O2 Therapy. Inj. LORAZEPAM 2U Stat was given. However, she did not have spontaneous resolution. At 10pm, she suddenly collapsed and with cessation of spontaneous resolution. 

• PR- not recordable
• BP- NR
• Pupils - fixed, dilated
• ECG- flatline in all 12 leads at 10:05pm 
  
  19/5/21

IMMEDIATE CAUSE OF DEATH 

Seizures with Type II Respiratory Failure 

ANTECENDANT CAUSE OF DEATH

Severe COVID-19 Pneumonia 

Under the guidance of Dr. Sai Charan sir and Dr. Vamshi Krishna sir