A 49 year old male with Viral pneumonia secondary to COVID-19

Kausalya Varma, MBBS 8th semester

Roll no: 59

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. 

A 49 year old male with Viral pneumonia secondary to COVID-19 

Following is the view of my case (history as per date of admission):

CASE-

A 49 year old male patient was brought to the casualty by his son on 12/05/21 at 8:40am with the chief complaint of unconsciousness since 6 am.

HOPI-

- The patient was brought to the casualty in an unresponsive state at 8:40am

- He had been complaining of a headache since the previous night, which was bi-temporal and not associated with vomiting, nausea, giddiness, sweating, blurring of vision, loss of consciousness or blackout.

- He experienced involuntary movements of the upper and lower limbs and 3 episodes of involuntary micturition starting from 3am.

- He had episodes of loss of consciousness followed by sudden onset of shortness of breath starting from 6am. 

- Each episode lasted for around 30-60 seconds, and the patient did not regain consciousness after the third episode.

- He had Grade IV SOB, without chest pain, palpitations, decreased urine output, pedal edema or facial puffiness.

- On presentation, the patient was unresponsive. He had a GCS score of 5 (E3V1M1) and was febrile with a temperature of 102 F.

- The patient tested positive for COVID-19 15 days back and has been on Inj. Remdesivir and Inj. Clexane for the past 5 days.

PAST HISTORY-

- Patient was apparently asymptomatic until 9 years back (ie 2012), when he complained of retrosternal chest pain lasting for 8 hours.

- An ECG and 2D Echo were done and were evaluated as ACS (Acute coronary syndrome)- AW ST elevated myocardial infarction (AWSTEMI).

-  Moderate LV dysfunction was seen, and S/P PTCA and stent to the left anterior descending artery (LAD) was done on 1/3/12.

- Blood tests were done, and RBS- 219mg/dl, PLBS- 179mg/dl, Hb1AC- 7.3 were seen, and the patient was diagnosed with Type 2 Diabetes Mellitus.

History of medication-

At the first discharge after surgery, patient was given:

- Tab Ecosporin 325mg OD

- Tab Ceruvin 75mg PO/BD

- Tab Aztor 40mg 

- Tab Actiblock IPR 25mg 

- Tab Hopace 2.5mg

- Tab Gluconorm G1 PO/BD

Medication was adjusted 6 months later:

- Tab Ecosporin gold 20mg

- Tab Sustamet 25mg

- Tab Ramistar 5mg

- Tab Gluconorm G1 PO/BD

- Tab Lasilactone 1/2 tab- 25mg

- Advised to take less salt and decrease nonveg consumption

Same medication was continued until 2015:

- Tested PLBS- 154mg/dl

- Tab Concor 

- Tab Rosutor gold 20mg

- Tab Dytor plus 5mg

- Tab Amaryl 

Medication was again adjusted in 2016:

- PLBS- 166mg/dl

- Tab metformin XL- R(25/25)

- Tab Dytor plus 5mg

- Tab Glador M1 PO/BD

Same medication was continued and the patient was on regular follow up until December 2020.

PERSONAL HISTORY-

Occupation- Farmer

Appetite- decreased since the past 15 days

Diet- Mixed

Sleep- Adequate

Bowel/Bladder- Normal

Habits/Addictions- The patient used to regularly consume alcohol until 2012 after which he largely decreased consumption. He occasionally consumes toddy.

He has a habit of tobacco smoking for the past 20 years.

Family History is not relevant in this case.

GENERAL EXAMINATION-

Pallor- Absent

Icterus- Absent

Clubbing- Absent

Cyanosis- Absent

Lymphedenopathy- Absent

Edema- Absent

Malnutrition- Absent

Dehydration- Absent

VITALS (on admission):  

Temperature- Febrile (102 F)

BP- 120/80 mm Hg

Pulse- 103 bpm

Respiratory Rate- 30 cpm

Oxygen saturation- 90% on room air, 96% on 8L of O2

GRBS- 230 mg/dl 

SYSTEMIC EXAMINATION-

RESPIRATORY SYSTEM- 

- Dyspnea is present

- Position of the trachea is central

-Vesicular breath sounds are present

- Adventitious sounds- Right sided crepitus is heard in ISA and IAA. 

CVS- S1 and S2 heard, no added murmurs

PER ABDOMEN- Soft and tender, No organomegaly

CNS-

- Level of consciousness- E3V1M1; The patient is drowsy

- Pupillary and corneal reflexes are present

- Pupils reacting normally to light

- Dolls eye- positive

- Speech- patient is non responsive

- Glasgow Coma Scale- E3V1M1 

- Motor system examination: 

Power- 

	RIGHT	LEFT
UPPER LIMB	1/5	1/5
LOWER LIMB	1/5	1/5

Tone- Normal

Reflexes-

	BICEPS	TRICEPS	SUPINATOR	KNEE	ANKLE
RIGHT	+	+	+	+	+
LEFT	2+	2+	2+	2+	+

PROVISIONAL DIAGNOSIS- 

Severe COVID-19 with hypoxic ischaemic encephalopathy. 

The following investigations were ordered- Hemogram, RFT, LFT, MRI Brain, HIV, HBsAg, HCV

INVESTIGATIONS-

1) RFT- 

Creatinine- 0.7 mg/dl

Phosphorous- 2.0 mg/dl

Sodium- 131 mEq/L

2) LFT- 

Total bilirubin- 2.03 mg/dl

Direct bilirubin- 0.78 mg/dl

SGPT (ALT)- 93 IU/L 

Alkaline Phosphate- 154 IU/L

Total proteins- 5.7 g/dl

Albumin- 3.12 g/dl

3) Blood sugar-

FBS- 230 mg/dl

4) Hemogram-

Total count- 14300 cells/cumm

Lymphocytes- 13%

5) APTT test-

6) Prothrombin time-

7) Color Doppler 2D Echo-

- LAD Akinetic, No AS/MS, Sclerotic AV

- Moderate LV dysfunction

- No diastolic dysfunctions

8) MRI Brain-

- Observed- Symmetrical foci of restricted diffusion in bilateral frontoparietal parasagittal areas. 

These are suggestive of Acute bilateral parasagittal frontoparietal infarcts (watershed infarcts)

- Also seen are old infarcts with encephalomacic changes and surrounding gliosis in right frontal and parietal lobes.

FINAL DIAGNOSIS- 

Severe COVID-19 Pneumonia and Hypoxic Ischaemic Encephalopathy 

S/P- CABG

Heart Failure with Mid range ejection fraction

TREATMENT HISTORY-

The patient was admitted to the COVID-19 ICU, where he was continuously monitored and his treatment was recorded in the form of progress notes by the doctors in charge.

The treatment timeline is as follows-

On 12/05/21 (6:45pm)

- The provisional diagnosis is viral pneumonia secondary to COVID-19 infection.

- Suspecting viral encephalitis/ Hypoxic Ischaemic Encephalopathy with old infarcts in the right frontal and parietal lobes with post PTCA LAD territory (2012) with type 2 diabetes mellitus.

O/E- Patient is unconscious

Pulse- 122 bpm

SpO2- 86 on 15lt O2

RR- 46cpm

Non responsive to commands/pain- E1V1M1

Rx-

- O2 inhalation to maintain SpO2 > 90% (Intermittent BiPAP)

- Inj Ceftriaxone 1g IV/BD

- Inj Pantop 40mg IV/BD

- Inj Levipril 500mg IV/BD

- Tab Ecosprin 75mg OD

- Tab Clopidogrel 75mg OD

- Tab Atorovas 40mg OD

- Duolin, Budecort nebulisation every 6 hours

- GRBS every 6 hours

- Inj HAI 8am-2pm-8pm

- Temp charting 4 hourly

- Watch for seizure attack

- Monitor PR, BD, SpO2 every hour

- Inj Dexamethasone

- Inj Neomol 1mg TV TID

- Temp Charting every 4 hours

On 12/05/21 (8:00pm)

- The patient had progressive breathlessness since morning

- MRI Brain revealed B/L acute fronto parietal infarcts; features suggestive of metabolic encephalopathy (Hypoxic Ischaemic Encephalopathy)

- Airway- patent

- Breathing- Spontaneous

- Circulation- PR- 116bpm, BP- 130/70mmHg

- RR- 53cpm; SpO2- 60% with room air and 85-87% with face mask

- GCS- E1V1M1

- Temp- 104.5 F

- LP for CSF analysis was attempted but could not be done

- Ryles tube was inserted

Rx- 

- O2 Therapy via a face mask

- Inj Dexamethasone 6 hourly IV TID

- Inj Neomol QID

- Temp charting 4 hourly

On 13/05/21 (9:00am)

- Patient is unconscious

- GCS- E1V1M1

- PR- 114bpm, BP- 80/60mmHg

- O2 Saturation- 81% on 16L of O2

Rx- 

- Inj Levipil 500mg/BD

- Ryles tube insertion

- Tab Ecosporin 75mg/OD

- Tab Clopidogrel 75mg/OD

- Tab Atorovas 40mg

- BP, PR, Temp should be monitored hourly

- Inj PAN 40mg IV/OD

- Inj Mannitol 100mg IV/OD

- Inj HAI

- Inj Dexamethasone 6mg IV TID

- RT feed <100ml of milk and protein powder- every 2 hourly

- O2 Inhalation via face mask

- Inj Neomol 1g IV TID

- Temp charting hourly

- Tepid sponging 

On 13/05/21 (evening)

Unfortunately, the patient had passed away on 13/05/21 evening, two days after getting admitted.

Death notes- 

- Since admission, the patient was diagnosed with Hypoxic ischaemic encephalopathy with COVID-19 severe pneumonia. Patient was admitted to the ICU and was administered O2 therapy; SpO2 with 16lt O2 was 80%; Respiratory rate was 60cpm from the day of admission.

- The patient suddenly collapsed at 5:10pm. 

- Pupils were fixed and dilated

- ECG showed flat line at 5:21pm

- Immediate cause of death- Sudden cardiac arrest due to Hypoxic Ischaemic Encephalopathy.

- Antecedent cause of death- COVID-19 Pneumonia

QUESTIONS-

1) What do you think are the factors in this patient that contributed to his increased severity in symptoms?

2) What is the relationship between ACS and the progression of COVID in this case? Could it have been a driving factor in increased severity of symptoms?