51 year old female with Shortness of breath ,Fever ,Cough
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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
I have 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.
Under the guidance of Dr. Chandana
M. Abhignya , 8thSem , Roll.No. 71
26.05.21
Case
51 year old female patient came to the OPD on 24.05.21 with the chief complaints of
Shortness of breath at rest since 5days
Cough since 3days
Fever since 3days
History of present illness
Patient was apparently asymptomatic 5 days back and then she developed
shortness of breath since 5days which was insidious in onset and gradually progressed to Grade4
Cough since 3 days which is productive with scanty mucoid sputum
High grade fever sine 3 days which was insidious in onset, intermittent in nature not associated with chills and rigor
Cold since 3 days
Drowsiness and Irrelevant talk since morning on the day of admission
No history of chest pain , headache ,loss of taste and smell
pt. got tested positive for COVID 19 via RAT on 22.05.21 for which she was admitted
Past history
pt was COVID 19 positive 1 year back and received symptomatic treatment
Pt. is a known case of Type 2 Diabetes mellitus since 5yrs and has been on regular medications
not a k/c/o Hypertension ,asthma ,TB,CAD
Personal history
Diet - mixed
Appetite - decreased
Bowel and bladder movements - regular
No allergies
No addictions
Family history - not significant
General Examination
The patient is examined with informed consent.
Patient is consious, coherent, cooperative,is well oriented to time,place,person.
she is Moderately Built and nourished.
Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent
VITALS:
On the day of admission- 24/05/2021
Temperature-101 F
Pulse Rate - 88 beats/min
Blood pressure-120/70mmhg
Respiratory rate - 18 cycles/min
SPO2 - 93% at room air
GRBS - 552 MG/DL
25/05/2021
Pt is agitated and irritative
Temperature - 100 F
Pulse rate - 108 beats/min
Blood pressure - 110/60 mm Hg
SPO2 - 9O% at room air
GRBS - 146 mg/dl
26-05-2021
Pt is irritable and drowsy
Temperature - 99F
Pulse rate - 67beats/min
Blood pressure - 110/60 mm Hg
SPO2 - 94% at room air
RR - 24 cpm
GRBS - 236MG/DL
27-05-21
Pt is irritable
Temperature - afebrile
Pulse rate - 101beats/min
Blood pressure - 110/80 mm Hg
SPO2 - 96% at room air
RR - 23cpm
GRBS - 277MG/DL
28-05-21
Pt is C/C/C
Temperature - afebrile
Pulse rate - 94beats/min
Blood pressure - 120/80mm Hg
SPO2 - 95% at room air
RR - 24 cpm
GRBS - 209MG/DL
29-05-21
Pt is C/C/C
Temperature - afebrile
Pulse rate - 95beats/min
Blood pressure - 120/80mm Hg
SPO2 - 94% at room air
RR - 22 cpm
GRBS - 253MG/DL
31-05-21
Pt is C/C/C
Temperature - afebrile
Pulse rate - 98beats/min
Blood pressure - 120/80mm Hg
SPO2 - 99% at room air
RR - 22 cpm
on 01.06.21
Pt is C/C/C
Temperature - afebrile
Pulse rate - 94beats/min
Blood pressure - 110/80mm Hg
SPO2 - 99% at room air
RR - 21cpm
SYSTEMIC EXAMINATION
on 27.05.21
CVS - S1 and S2 heard
No added thrills,murmurs
RESPIRATORY SYSTEM - BAE (+)
PER ABDOMEN : soft, non tender, no organomegaly
CNS - HMF intact
not oriented to time ,place and person
on 28.05.21
CVS - S1 and S2 heard No added thrills,murmurs
RESPIRATORY SYSTEM - BAE (+)
PER ABDOMEN : soft, non tender, no organomegaly
CNS - HMF intact oriented to time ,place and person
on 31.05.21
CVS - S1 and S2 heard
No added thrills,murmurs
RESPIRATORY SYSTEM - BAE (+)
PER ABDOMEN : soft, non tender, no organomegaly
CNS - HMF intact
oriented to time ,place and person
on 01.06.21
CVS - S1 and S2 heard
No added thrills,murmurs
RESPIRATORY SYSTEM - BAE (+)
PER ABDOMEN : soft, non tender, no organomegaly
CNS - HMF intact
oriented to time ,place and person
Investigations
CBP
Haemoglobin - 12.5gm/dl
TLC : - 10,700cells/cumm
Neutrophils - :75%
Lymphocytes -15%
Eosinophils -04%
Monocytes: -06%
Basophils: -0%
Platelet count: -2.60akhs/cumm
CRP - 2.4
D-Dimer - 570ng/dl
LDH - 237
LFT
Total bilirubin :2.63mg/dl
Direct bilurubin:0.52mg/dl
AST 36IU/L
ALT 36IU/L
ALP 312IU/L
Total proteins :6.5gm/d
Albumin :3.2gm/,dl
A/G RATIO :0.97
RFT
Urea :107mg/dl
Creatinine: 1.4 mg/dl
Uric acid: 11.2 mg/dl
Calcium: 9.2mg/dl
Phosphorous:3.6mg/dl
Sodium :137mEq/L
Pottasium: 5.5mEq/L
Chloride :104mEq/L
Arterial blood gas
PH : 7.35
Pco2 :19.2.
Po2: 62.2
HCO3 : 10.7
St.HCO3:14.2
sPo2 88.3
CUE
Urine ketone bodies -negative
Colour:Pale yellow
Appearance: Clear
Reaction: Acidic
Sp Gravity: 1.01
Albumin ++
Sugar: +++
Bile salts: Nil
Bile pigments: Nil
Pus cells: 3-4
Epithelial cells :1-3
Red blood cells :Nil
Crystals: Nil
Casts:Nil
Amorphous deposits:Absent
Others: Nil
FBS 425MG/DL
HIV- Neg
HbsAg -neg
Left middle lobe opacity found
ECG
on 25.05.21
serum osmo on 25.05.21 - 330osm/kg
on 26.05.21
serum osmo on 26.05.21 - 300osm/kg
RFT
Urea :76mg/dl
Creatinine: 1.1 mg/dl
Uric acid: 6.9 mg/dl
Calcium: 10.1mg/dl
Phosphorous: 3mg/dl
Sodium :136mEq/L
Pottasium: 4.5mEq/L
Chloride :104mEq/L
on 27.05.21
RFT
BUN 21.4
Urea :46mg/dl
Creatinine: 1 mg/dl
Uric acid: 3.8mg/dl
Calcium: 9.9mg/dl
Phosphorous: 2.5mg/dl
Sodium :131mEq/L
Pottasium: 4.1mEq/L
Chloride :101mEq/L
RBS -277mg/dl
Hemogram
Hb - 11.7gm/dl
TLC -10,500cells/cumm
Platelets - 2.05lc/cumm
Serum osm - 285osm/kg
on 28.05.21
CBP
Hb - 11.gm/dl
TLC -14,000cells/cumm
Neutrophils - :80%
Lymphocytes -13%
Eosinophils -03%
Monocytes: -04%
Basophils: -0%
Platelets - 2.19lc/cumm
Treatment
ON 24.05.21
O2 suplementation- to maintain SpO2 > 92%
IVF - 20NS continuous
10 RL 100ml per hr
with 1 ampule OPTINEURON
Tab: Dolo 650 mg/po/sos
Tab: Pantop 40mg/IV/OD
Tab: Limcee/po/OD
Start Insulin ACTRAPID infusion IV
Start on 6units/hr
Monitoring vitals
GRBS charting hourly
Inj. NEOMOL 100ml IV if temp >102F
on 25.05.21
O2 suplementation- to maintain SpO2 > 92%
IVF - NS @75ml/hr
Tab: Dolo 650 mg/po/sos
Tab: Pantop 40mg/IV/OD
Tab: Limcee/po/OD
Start Insulin ACTRAPID infusion IV
based on GRBS
Nebulization- Duolin & Mucomist 8th hourly
Budecort 12th hourly
Inj. Clexane 40mg/sc/OD
Inj REMDESIVIR 200mg/IV/stat followed by 100mg/IV/OD
Monitoring vitals
Strict I/O charting
on 26.05.21
Head end elevation
O2 suplementation if needed- to maintain SpO2 > 92%
IVF - NS @100ml/hr
Tab: Dolo 650 mg /po/ sos
Tab: Pantop 40mg/IV/OD
Tab: Limcee/po/OD
Inj.Human ACTRAPID Insulin S.C ( GRBS-238mg/dl)
6AM-----2PM-----8PM
Nebulization- Duolin & Mucomist 8th hourly
Budecort 12th hourly
Inj. Clexane 40mg/sc/OD
Inj REMDESIVIR 100mg/IV/OD
Monitoring vitals
Strict I/O charting
GRBS monitoring 2nd hourly
on 27.05.21
Inj REMDESIVIR 100mg/IV/OD
Inj. Clexane 40mg/sc/OD
Inj .NPH Insulin SC pre-meal
10U(8AM)---------10U(8PM)
Inj HAI S/C
8AM---1PM----8PM
GRBS monitoring 2nd hourly
IVF - NS @100ml/hr
Tab: Dolo 650 mg /po/sos
Tab: Pantop 40mg/IV/OD
Tab: Limcee/po/OD
Inj.Human ACTRAPID Insulin S.C
6AM-----2PM-----8PM
Nebulization- Budecort and mucomist 8th hourly
O2 suplementation to maintain SpO2 > 93%
Temp monitoring 4th hourly
Spirometry , Prone positioning
MONITORING VITALS
Insulin Dosage
Time GRBS Insulin given
8AM 298mg/dl Inj. HAI 8U
Inj. NPH 10U
10AM 369mg/dl
Inj.HAI 12U
12PM 274mgdl
on 28.05.21
Inj REMDESIVIR 100mg/IV/OD
Inj. Clexane 40mg/sc/OD
Inj .NPH Insulin SC pre-meal
10U(8AM)---------10U(8PM)
Inj HAI S/C
8AM---1PM----8PM
GRBS monitoring 2nd hourly
8AM---1PM---8PM---2AM
IVF - NS @75ml/hr continuous infusion
Tab: Dolo 650 mg /po/sos
Tab: Pantop 40mg/IV/OD
Tab: Limcee/po/OD
Nebulization- Duolin & Mucomist 8th hourly
Budecort 12th hourly
Temp monitoring 4th hourly
Monitor vitals
Spirometry , Prone positioning
On 29.05.21
Inj REMDESIVIR 100mg/IV/OD
Inj. Clexane 40mg/sc/OD
Inj .NPH Insulin SC pre-meal
10U(8AM)---------10U(8PM)
Inj HAI S/C
8AM---1PM----8PM
GRBS monitoring 2nd hourly
8AM---1PM---8PM---2AM
IVF - NS @75ml/hr continuous infusion
Tab: Dolo 650 mg /po/sos
Tab: Pantop 40mg/IV/OD
Tab: Limcee/po/OD
Nebulization- Duolin & Mucomist 8th hourly
Budecort 12th hourly
Temp monitoring 4th hourly
Monitor vitals
Spirometry , Prone positioning
On 30.05.31
Insulin Dosage
Time GRBS Insulin given
8AM 293mg/dl Inj. HAI 10U
Inj. NPH 10U
2PM 314mg/dl Inj.HAI 10U
12PM 124mgdl Inj.HAI 2U
Inj. NPH 10U
On 31.05.21
Inj. Clexane 40mg/sc/OD
Inj .NPH Insulin SC pre-meal
10U(8AM)---------10U(8PM)
Inj HAI S/C
8AM---1PM----8PM
GRBS monitoring 2nd hourly
IVF - NS @75ml/hr continuous infusion
Tab: Dolo 650 mg /po/sos
Tab: Pantop 40mg/IV/OD
Tab: Limcee/po/OD
Nebulization- Duolin & Mucomist 8th hourly
Budecort 12th hourly
Temp monitoring 4th hourly
Monitor vitals
Spirometry , Prone positioning
Insulin Dosage
Time GRBS Insulin given
8AM 149mg/dl Inj. HAI 2U
Inj. NPH 10U
2PM 305mg/dl Inj.HAI 14U
4PM 252mg/dl
7PM 338mgdl Inj.HAI 14U
Inj. NPH 14U
11PM 347mg/dl
On 01.06.21
Inj. Clexane 40mg/sc/OD
Inj .NPH Insulin SC pre-meal
14U(8AM)---------14U(8PM)
Inj HAI S/C according to s/s
8AM---1PM----8PM
GRBS monitoring 6thhourly
IVF - NS @75ml/hr continuous infusion
Tab: Dolo 650 mg /po/sos
Tab: Pantop 40mg/IV/OD
Tab: Limcee/po/OD
Nebulization- Duolin & Mucomist 8th hourly
Budecort 12th hourly
Temp monitoring 4th hourly
Monitor vitals
Spirometry , Prone positioning
Insulin Dosage
Time GRBS Insulin given
2AM 215mg/dl Inj. HAI 2U
Inj. NPH 10U
8AM 246mg/dl Inj.HAI 8U
Inj. NPH 14U
DIAGNOSIS
Moderate COVID-19 Pneumonia , Hyperosmolar hyperglycemic non ketotic syndrome(HHNS)/ Hyperosmolar Hyperglycemic Syndrome(HHS) with Acute kidney injury(AKI)
Hyperosmolar Hyperglycemic State/Syndrome
* Hyperosmolar hyperglycemic syndrome (HHS) is a clinical condition that arises from a complication of diabetes mellitus. Type 2 diabetes accounts for about 90% to 95% of diabetes cases.
* It is most commonly seen in patients with obesity. As a consequence of the obesity and high body mass index (BMI), there is the resistance of the peripheral tissue to the action of insulin.
* The beta-cell in the pancreas continues to produce insulin, but the amount is not enough to counter the effect of the resistance of the end organ to its effect.
* HHS is a serious and potentially fatal complication of type 2 diabetes.
* The mortality rate in HHS can be as high as 20% which is about 10 times higher than the mortality seen in diabetic ketoacidosis.
What causes hyperosmolar hyperglycemic syndrome (HHS)?
People who have diabetes have too much glucose (sugar) in their blood. The glucose builds up because their bodies either don’t make enough insulin, or have trouble using the insulin that they do make. (Insulin is a naturally occurring hormone, produced by the beta cells of the pancreas, which helps the body use sugar for energy.)
HHS occurs when the blood sugar of a person with diabetes becomes too high (hyperglycemia) for a long time.
The extra sugar is passed into the urine, which causes the person to urinate frequently. As a result, he or she loses a lot of fluid, which can lead to severe dehydration (extreme thirst).(osmotic diuresis)
HHS usually develops in people who do not have their type 2 diabetes under control and they:Have an illness or infection, such as pneumonia or a urinary tract infection.
- Stop taking medication to manage their diabetes.
- Have a heart attack or stroke.
- Take certain medications—such as steroids or diuretics—that can cause the syndrome
What are the symptoms of hyperosmolar hyperglycemic syndrome (HHS)?
Symptoms of HHS usually come on slowly, and can take days or weeks to develop. Symptoms include:
- High blood sugar level (over 600 mg/dL).
- Confusion, hallucinations, drowsiness or passing out.
- Dry mouth and extreme thirst that may eventually get better.
- Frequent urination.
- Fever over 100.4 degrees Fahrenheit.
- Blurred vision or loss of vision.
- Weakness or paralysis that may be worse on one side of the body.
Treatment
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