45 YEAR OLD FEMALE WITH VIRAL PNEUMONIA SECONDARY TO COVID INFECTION

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SNEHA CHAUHAN 

ROLL NO 126

MBBS 8th SEMESTER 



  • This is an online E-log to discuss our patient’s de-identified health data shared after taking hi/her/guardian’s 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 also reflects my patient centered online learning portfolio and your valuable inputs on comment box are welcome. 


I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competence in reading and comprehending clinical data including history, clinical findings and come up with diagnosis and treatment plan. 



Following is the view of my case-


CASE:


A 45 year old female came to the OPD with chief complaints of 

  • FEVER- since 1 week 
  • DRY COUGH- since 1 week 
  • LOSS OF APPETITE- since 1 week 
  • CHEST PAIN DURING DRY COUGH- since 2 days. 


Past History :

Not a known case of Hypertension, DM, Epilepsy and CKD. 



Drug History :

No significant drug history.



Personal History :

Diet: Mixed 

Appetite: Decreased

Sleep: Adequate 

Bowel and Bladder movements: Regular 

Addictions: None 


Family History :

  • No history of similar complaints in the family,
  • No history of Diabetes, Hypertension, Heart disease, Cancers, Tuberculosis, Asthma, or any hereditary disease in the family. 


General Examination :

  • The patient is examined in a well lit room, with informed consent. 
  • The patient is conscious, coherent and cooperative at the time of examination.

 


Systemic Examination :

  1. Cardiovascular system- S1 and S2 heart sounds heard,  no added murmurs or thrills. 
  1. Respiratory system- Normal vesicular breath sounds heard
  1. Per Abdomen- soft, non tender, no organomegaly. Normal bowel sounds heard.
  1. Central Nervous System- Intact


Vitals :

Day1 - 11/05/2021 Day of admission

  • Patient was conscious and coherent 
  • Pulse Rate (PR)- 88 beats/min
  • Blood Pressure (BP)- 100/70 mm of Hg
  • Respiratory Rate (RR)- 24 cycles/min
  • Temperature- 98.6 ° F 
  • SPO2- 98% with 15 L of O2

Day 2- 12/05/2021

  • Patient is conscious and coherent 
  • PR- 88 beats/min
  • BP- 110/70 mm of Hg
  • SP02- 99% with 10L of O2
  • Temperature- 97°F

Day 3- 13/05/2021

  • PR- 84 beats/min
  • BP- 106/70 mm of Hg
  • SPO2- 96% with 10L of O2

Day 4- 14/05/2021

  • Patient is conscious and coherent 
  • PR- 90 beats/min
  • Temperature- 98.4°F
  • SPO2- 90-98% with 10L of O2
  • Complains of- Dry mouth and Breathlessness 

Day 5- 15/05/2021

  • PR- 86 beats/min
  • BP- 110/70 mm of Hg
  • Temperature- Afebrile
  • SPO2- 99% with 15 L of O2

Day 6- 16/05/2021

  • Patient is conscious, coherent and cooperative 
  • PR- 97 beats/min
  • BP- 120/80 mm of Hg
  • SPO2- 98%
  • RR- 22 cycles/min
  • GRBS- 205 mg/dl

Day 7- 17/05/2021

  • Patient is conscious, coherent and cooperative 
  • PR- 89 beats/min
  • BP- 110/60 mm of Hg
  • Temperature- Afebrile 
  • SPO2- 96% on 10L of O2

Day 8- 18/05/2021- Day of discharge 

  • Patient is conscious, coherent and cooperative 
  • PR- 86 beats/min
  • BP- 110/70 mm of Hg
  • SPO2- 95% on 2L of O2
  • Temperature- Afebrile

Investigations :

  1. CBP
On 11/05/2021-
  • Haemoglobin- 12.9 g% (normal range- 13-17 g%)
  • Total Leukocyte count- 4000 cells/cumm
  • Differential Leukocyte count-

            - Neutrophils : 67 % ( normal- 40-80)

            - Lymphocytes : 28% (normal- 20-40)

            - Eosinophils : 2% (normal- 1-6)

            - Monocytes : 3% (normal- 2-10)

  • Platelet count- 1.51 lakh/cumm (normal range— 1.5-4.1)

On 16/05/2021-
  • Haemoglobin- 12.3 g%
  • Total Leukocyte count- 10,500 
  • Differential Leukocyte count- 

        - Neutrophils : 63%

           - Lymphocytes : 11%

           - Eosinophils: 3%


  1. CRP-  On 11/05/2021– Positive 0.6 mg/dl
                    On 16/05/2021- 2.4 mg/dl

  1. D-Dimer- On 11/05/2021- 1150 ng/ml (normal range < 200 ng/ml)
                         On 16/05/2021- 980 ng/ml 
  1. LFT- 
  • ALP (Alkaline Phosphate) : 106 IU/L (normal range- 53- 128)
  • SGOT (AST) : 41 IU/L (normal range- 0-35)
  • SGPT (ALT) : 40 IU/L (normal range- 0-45)
  • Total Proteins : 6.2 g/dl (normal range- 6.4-8.3)
  1. RFT- Normal 
  1. Serum LDH- 518 IU/L ( normal range- 140-280)
  1. X ray Chest 
  • On 11/05/2021 at 6:45pm  




  • On 17/05/2021 at 9:45 pm  



  1. ECG- 



Provisional Diagnosis :

Viral Pneumonia secondary to COVID-19 infection. 

HRCT- CORADS 5

CT score- 6/25


Treatment Regimen : (11/05/2021- 18/05/2021)

  1. IVF—75ml/hr Inj. OPTINEURON
  2. O2 supplementation to maintain SPO2 > 90%
  3. Nebuliser- Duolin, Budefort, every 6th hourly
  4. Inj. PANTOP 40mg IV/OD
  5. Tab MVT OD
  6. Tab LIMCEE OD
  7. Tab DOLO 650mg
  8. Syp GRILLINCTUS 2tsp 1-1-1
  9. Inj. DEXAMETHASONE 8mg/IV/OD
  10. Inj. CLEXANE 40 mg SC/BD
  11. Pulse rate, Blood pressure, and SPO2 monitoring hourly 
  12. Temperature charting every 4th hourly


Additional medication-


11/05-2021

  • GRBS monitoring every 6th hourly

12/05-2021

  • Inj. CLEXANE 40mg/SC/BD started

13/05-2021

  • Inj. HAI 4U-4U-4U started

15/05-2021

  • GRBS monitoring every 2nd hourly

16/05-2021

  • Inj. HAI increased to 8U-8U-8U
  • Tab SPOROLAC TID
  • ORS

18/05-2021

  • Tab SPOROLAC stopped 
  • ORS stopped 
  • Syrup CREMAFFIN given 


Patient was discharged on 18th May 2021, at 5pm. 

Duration of stay- 8 days.


Questions- 

Q1. Is there a relation between Covid-19 infection and serum LDH levels? 


Q2. Despite being not a known case of Diabetes, what is the reason for her GRBS being high?



Under the guidance of Dr. Sai Charan Sir. 



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