54 YEAR OLD FEMALE WITH COMPLAINTS OF BREATHLESSNESS SINCE 7 DAYS
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 54 year old female from Nalgonda presented to the hospital at 10pm on 5th May 2021 with the chief complaints of Shortness of Breath (SOB) since 7 days.
HISTORY OF PRESENTING ILLNESS:
The patient was apparently asymptomatic 7 days ago when she developed Shortness of Breath (SOB) which was sudden in onset, initially gradually progressive, but later rapidly progressive 4 days ago, from Grade 2 to Grade 4 SOB (NYHA classification). It was associated with positional variation, with the SOB getting worse in sleeping position and being relieved on sitting. No other aggravating or relieving factors were noted.
There was also a history of fever which started 7 days ago, and subsided 4 days ago.
She has also had Rheumatoid Arthritis and Hypothyroidism since 4 years, for which she has been taking treatment. The patient also had schizophrenia, although the attender would not specify since when.
Following initial general examination, the patient was asked to be admitted in the hospital. However, she refused and requested to be sent to another hospital where she knew a PG against medical advice, despite being fully informed of the gravity of her situation.
On admittance to the new hospital, RTPCR was performed which was positive for COVID-19. The patient was immediately intubated and put on mechanical ventilation. However, before any further investigations could be performed, the patient (sadly) passed away.
PAST HISTORY
No similar complaints in the past.
K/C/O Rheumatoid Arthritis, Hypothyroidism since 4 years.
K/C/O Schizophrenia since an unspecified amount of time.
Not K/C/O of DM, HTN, asthma, TB, epilepsy.
There were no known COVID positive patients in the family, and no similar complaints in any family members.
PERSONAL HISTORY
Diet: Mixed
Appetite: Reduced
Sleep: Disturbed
Bowel and Bladder movements: Regular
No addictions
DRUG HISTORY
1. Chronic methylprednisolone usage: 4mg OD: for Rheumatoid Arthritis
2. Tab. Eltroxin 25mg OD: for hypothyroidism
3. Tab. Sizodon 3mg BD: schizophrenia
4. Tab. Pacitane 2mg OD: schizophrenia
5. Tab. Amisulpiride 50mg occasionally: schizophrenia
Occasionally: Inj Haloperidol 1 ampoule: schizophrenia
GENERAL EXAMINATION
Patient was examined in a well- lit room with informed consent.
She was conscious, coherent and co-operative and well oriented to time, person, place. She was moderately built and well nourished.
Pallor: Present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent
Edema: Present
VITALS
PR: 121 beats/min
RR: 32 cycles/min
SpO2 level: 91% after 10 litres of O2
SYSTEMIC EXAMINATION
1. CARDIOVASCULAR SYSTEM:
-S1, S2 heard
2. RESPIRATORY SYSTEM:
-SOB present, grade 4 (NYHA)
-Wheeze present
-Position of trachea central
-Tubular breath sounds sounds
-Auscultation: Rales heard
3. ABDOMEN:
-Shape: Distended, not tender
-No bruits or free fluid
-Liver and spleen not palpable
-Bowel sounds heard
4. CNS EXAMINATION:
-Conscious, coherent, co-operative
-Normal speech
-Cranial nerves, sensory and motor system normal
Glasgow coma scale- 15/15 (E4V5M6)
On examination, Cushingoid features were noted owing to steroid (Methylprednisolone) overuse, for treatment of Rheumatoid Arthritis:
-Moon facies present
-Abdominal distension present
-Skin ecchymoses present
-Proximal myopathy
PRELIMINARY INVESTIGATIONS ORDERED:
1. GRBS
2. CRP levels
3. Hb levels
4. ECG
TREATMENT ADVISED:
1. O2 inhalation to maintain SpO2 greater than 90%
2. Tab. PCM 650mg PO/SOS
3. Inj. Dexamethasone 8mg/IV/OD
4. Tab. Thyronom 25mg PO/OD
5. Inj Pantop 40mg/IV/OD
6. Nebulisation with Duoilin, Budecot, Mucomist 8 hourly
7. Tab Limcee PO/OD at 2pm
8. Inj Clexane 40mg/SC/OD
9. Tab. Zincovet PO/OD at 2pm
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