A 72 years old Male came with breathlessness and fever since 3 days

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June 11th 2021

Paramkusham Sai krupa sri 

Roll. No : 175 

A case discussion of 

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.

CASE PRESENTATION:

A 72 years old Male came with breathlessness and fever since 3 days 

CHEIF COMPLAINTS:  of breathlessness and fever since 3 days 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 days back 

then he developed breathlessness, fever since 3 days which is rapidly progressive and requiring  high  flow O2 

PAST HISTORY: 

Hypertension since 20 years 

Tab LOSAR-H 40/12.5 M - OD

Tab CINOD 20mg - OD

Not a known case of Diabetes, TB, Asthma, epilepsy. 

PERSONAL HISTORY :

Diet : mixed

Appetite :  lost 

Bowel and bladder : regular ( requires laxative use - chronic) 

Micturition : normal 

No Addictions

FAMILY HISTORY:

Not significant.

GENERAL EXAMINATION: 

Patient is conscious, coherent and cooperative.

He is well oriented to time, place and person. 

He is moderately nourished.

Cyanosis is present both central and peripheral

No Pallor

No Icterus 

No Clubbing

No Lymphadenopathy

No Edema

VITALS: 

Pulse rate - 104 bpm

Respiratory rate -  36 cycles/min 

SPO2 :85% at 15 liters of oxygen 

SYSTEMIC EXAMINATION:

Cardiovascular system : S1, S2 is heard. No murmurs are heard.

Respiratory system :Dyspnoea ,wheeze present

Position of trachea - central, 

Breath sounds - tubular ,

Adventitious sounds - rales 

Per Abdomen : Soft, Non-tender,  

CNS Examination : intact 

(Gasglow scale : E4V5M6) 

PROVISIONAL DIAGNOSIS:

Severe Covid-19 pneumonia and hypertension since 20 years. 

TREATEMENT HISTORY :

1) Inj. Pan 40mg IV/OD 

2) Inj. Dexamethasone 8mg IV/ TID 

3) IVF - 1ONS - optineuron @100ml/hr 

              1 ORS - thiamine @100ml/hr

4) Temp, SPO2 & PR & Bp monitoring 4th hourly 

5) Tab. Dolo 650mg P/O TID 

6) Head End elevation to 30°

7) GRBS charting 6th hourly 

8) Intermittent BIPAP at physicians call 

9) Nebulization with Duolin, budecort and mucomyst 8th hourly. 

Treatment history on 6/05/2021 

Vitals :

BP- 130/40mmhg 

PR-90bpm 

Spo2 - 40% at RA 85% at BIPAP 

GRBS- 150mg/dl  

Treatment : 

1)Intermittent BIPAP

2)Inj pantop 40mg/IV/OD inj 

3)Dexamethasone 8mg/IV/OD 

4)IVF- NS & DNS at optineuron &thiamine at 100ml/hr tab 

5)Tab. DOLO 850mg/PO/OD 

6)Nebuliser with duolin ,budecort mucomist at 8th hourly  

7)Temperature, BP, PR, CPO2 monitoring  

8) I/O Charting

9) Inj CLEAXINE 40mg(0.4 s.c.) S/C OD 

10) LOSAR-H. 40/125 - OD (mgNg) 8:00 am  

11) Tab CINOD 20mg - OD evening -6:00pm 

12) Tab mucinac 600 1tab  in half glass water  BID  

13) AUGMENTIN 62.5mg/PO/BD

Treatment history on 07/05/2021

Vitals

Temp - 98.F

BP- 130/80mmhg 

PR -80bpm 

SPO2 - 72% on BIPAP

Treatment : 

1)TAB AUGMENTIN 62.5mg/PO/OD

2)Inj pantop 40mg/IV/OD 

3)Inj Dexamethasone 8mg/IV/OD 

4) IVF - OPTINEURON in NS & THIAMINE in DNS @ 75 ml/hr

5)Tab.DOLO 650mg/PO/OD 

6)Nebuliser with duolin ,budecort mucomyst at 8th hourly  

7)Inj.CELXANE 40mg /S.C./ OD

8) Tab. LOSAR.H 40/12.5/PO/OD

9) Tab. CINOD 20mg/OD/6pm

10) Tab.MUCINAC 60 mg 1tab in half glass water 

11 ) BP, PR, SPO2 monitoring 

12) GRBS monitoring

Treatment history on 08/05/2021

Vitals :- 

PR : 93bpm 

SpO2 : 84% on BIPAP 

Treatment

1) Tab : Augmentin - 6.25 mg /PO/BD 

2) CPAP - NIV 

3) Inj. Pantop 40mg IV /OD

4) Inj. Dexamethasone 8mg IV /OD 

5) IVF - OPTINEURON in NS & THIAMINE in DNS @ 75 ml/hr

6) Tab. Dolo 650 mg/PO/TID

7) Nebulization with Duolin, budecort and mucomyst 8th hourly.

8) Inj. Clexane 40mg sc OD

9) Tab. Losar. H 40/12.5/PO/OD

10) Tab. Cinod 20mg /OD at 6pm 

11) Tab. Mucinac 600mg 1tab in half glass of water

Treatment history on 09/05/2021

Treatment : 

1)TAB AUGMENTIN 625mg/PO/OD

2) CPAP- NIV

3)Inj pantop 40mg/IV/OD 

4)Inj Dexamethasone 8mg/IV/OD 

5) IVF-NS &DNS at optineuron ,thiamine at 25ml/hr 

6)Tab. DOLO 650mg/PO/OD 

7)Nebuliser with duolin ,budecort ,mucomist at 8th hourly  

8)Inj CELXANE 40mg /S.C./ OD

9)Tab.LOSAR.H 40/12.5/PO/OD

10)Tab. CINOD 20mg/OD/6pm

11)Tab.MUCINAC 600mg 1tab in half glass water

10/05/2021

CPR notes 

1:35am : 

 At 12:50am the patient saturation started falling and he had to intubated at 12:50am with ET tube size of 7mm

 CPR had to be initiated because of not recurable pulse rate and blood pressure. 

12:50 am :

PR was NR 

BP was NR 

CPR was initiated 

12:55am :

PR was NR 

BP was NR 

CPR continued 

Inj / IV of epinephrine was given 

1:00am :

PR was NR 

BP was NR 

CPR was continued 

Inj /IV of epinephrine was given 

1:05am :

PR was NR 

BP was NR 

CPR continued 

Inj IV epinephrine given 

1:10 am :

PR was NR 

CRP continued 

Inj of IV epinephrine given 

1:15am :

PR was NR

BP was NR

CPR continued

Inj of IV epinephrine given

1:20 am :

PR was NR

BP was NR

The patient was declared dead at 1:22am on 10/05/2021 despite all the above resuscitative measures 

Immediate cause of death - cardiopulmonary arrest

Antecedent cause of death - COVID-19 pneumonia known case of hypertension

INVESTIGATIONS:

HEMOGRAM :

LIVER FUNCTION TEST : 

RENAL FUNCTION TEST : 

RANDOM BLOOD SUGAR : 

ABG : 

C - REACTIVE PROTEIN:

FERRITIN :

D-DIMER :

ERYTHROCYTE SEDIMENTATION RATE :

C-REACTIVE PROTEIN :

FERRITIN: 

ECG: 

X- RAY :