COVID IN 26 Y/O FEMALE

A 26 Year Old Female with Fever and Shortness of Breath

This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.

 A 26 year old female from Hyderabad presented to the hospital with the chief complaints of fever since 23 days, and shortness of breath since 18 days. 

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 23 days ago when she developed a fever, sudden in onset, intermittent in nature, increasing at night, with no associated chills and rigors.

She was tested for COVID via RTPCR on 23rd April 2021, and tested positive on 25th April. She was advised to take Zinc and multivitamin tablets, along with Fabiflu.

She developed grade II shortness of breath (NYHA classification) 18 days ago,  insidious in onset, gradually progressive, aggravated on exercise and relieved on resting. She was asked to get a CT scan the same day- CT severity was 23/25; CORAD 5. She was prescribed steroids and asked to practice proning.

On 4th May 2021, she was admitted due to SOB to Hospital-1, where she placed on a BiPAP machine. She was later shifted to Hospital-2 on 10th May, citing lack of funds.

On 11th May, the patient was sedated and intubated for mechanical ventilation as her SpO2 was below 30% on BiPAP. She had been on SIMV mode of mechanical ventilation till 16th May.

On 16th May, she developed AKI along with hypotension and tachycardia, associated with a feeble pulse. She was placed on AC/MV mode of mechanical ventilation, and noradrenaline was given along with IV fluids. Despite this, she (sadly) passed away in the afternoon.

She had also complained of dry cough (no discharge) from 23rd April, insidious in onset and intermittent in nature, with no diurnal or positional variations. No aggravating or relieving factors were noted. It gradually subsided after a week.

No history of headache, diarrhoea, chest pain, sore throat, loss of taste or smell.

PAST HISTORY

No similar incidents in the past.

Her family members, including her mother, brother, aunt, and grandmother, have all tested positive for COVID.

Not a known case of Hypertension, Diabetes, Asthma or Epilepsy.

PERSONAL HISTORY

Diet: Mixed

Appetite: Normal

Sleep: Disturbed

Bowel, bladder: Regular

No addictions

DRUG HISTORY

No known drug allergies. 

FAMILY HISTORY

Her family members, including her mother, brother, aunt, and grandmother, had all tested positive for COVID.

GENERAL EXAMINATION (at the time of admission)

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

The patient had altered sensorium, and was moderately built and well nourished.

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent

Edema: Absent 

Vitals: (at time of admission)

HR: 100bpm

BP: 100/60mmHg

RR: 34cpm 

Temp: 100°F

SpO2: 75% on 16L o2

SYSTEMIC EXAMINATION (at time of admission):

Respiratory System: Bilateral air entry positive

CVS: s1, s2 heard

CNS: Altered sensorium noted

INVESTIGATIONS 

1. General investigations- CBP, CRP, RFT, LDH.

        a. CBP

                           11/05/21                                                                  16/05/21

            -Hb: 15.2 g%                                                                    -Hb: 11.4 g%

            -Platelets: 2.43 lakhs/mm3                                               -Platelets: 1.2 lakhs/mm3

        b. CRP

             -Positive, 2.4mg/dl

        c. RFT

                              11/05/21                                                     16/05/21, following AKI             

                      -Bl. urea 53mg/dl                                                 -Blood urea: 58mg/dl

                      - S. creatinine: 0.6mg/dl                                       -S. creatinine: 3.5mg/dl

                      -S. Calcium: 10mg/dl

                      -Uric acid: 4.5mg/dl

                      -Phosphorus: 4.2mg/dl

          d. S. LDH

               -1169IU/L

          e. LFT

                    11/05/21                                                                             16/05/21

               -Bilirubin: 298 mg/dl                                                       -AST: 86IU/L

               -SGOT: 418IU/L                                                              -ALT: 223IU/L

               -SGPT: 487IU/L                                                                      

              -ALP: 118IU/L                                                                   -ALP:131IU/L

              -Albumin: 2.58g/dL                                                            -Albumin:2.9g/dL

2. CT severity: 23/25

    CORAD: 5

                                                                    HRCT: 29/4/2021

                                                     CRP, CBP, RFT, LFT, ABG: 11/05/21

3. ABG             

                                                                 ABG: 13/05/2021

4. D-dimer, coagulation indices: 

                                                   D-dimer, coagulation indices: 15/05/2021

5. ECG report:

                                                                ECG report: 11/05/21

6. SpO2 (currently): 92% on SIMV mode of mechanical ventilation, with 80% FiO2. 

    PEEP 6, VT-400

NOTE: D-Dimer and SpO2 levels: 

             On 12/05/2021: D-Dimer- 8690 ng/dl; SpO2- 85-90% with mechanical ventilation

             On  15/05/2021: D-Dimer- 2730ng/dl; SpO2- 92% with mechanical ventilation

PROVISIONAL DIAGNOSIS

Viral pneumonia secondary to COVID infection, with renal complications.

TREATMENT REGIMEN:

Before AKI:

1. Patient sedated and paralysed with inj midazolam

                                                            inj fentanyl infusion and 

                                                            inj vecuronium infusion 

2. On mechanical ventilation 

3. IVF NS and RL@75ml/hr

4. Duolin budecort nebulization 6th hourly 

5. Inj. Methylprednisolone 125mg iv TID

6. Inj. Levofloxacin 500mg Iv OD

7. Inj. Clexane 60mg BD

8. Inj. Pantop 40mg OD

9. Tab. Azithromycin 500mg OD

10. Tab. Mvt OD

11. Tab. Limcee OD

Following AKI, additionally:

1. Noradrenaline IV infusion

2. Dose alteration based on renal function