CASE OF A 36 YEARS OLD MALE WITH SEVERE VIRAL INTERSTITIAL PNEUMONIA

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I would like to thank Dr. Raveen sir (Gen Med PG) , Dr.Vamshi sir (Gen Med PG) and Dr. Anjali mam (Intern) for providing me the information related to the case. The following case history was taken over a phone call .

 This is a case of 36 years old male who came to the hospital on 29th May with :

CHIEF COMPLAINTS:

1) Fever since 5 days

2) Cough since 4 days

3) Shortness of breath since 4 days

HISTORY OF PRESENT ILLNESS :

The patient was apparently asymptomatic 5 days back then he developed a fever which was sudden in onset , intermittent in nature, evening rise of temperature associated with chills  .

The patient  got tested for COVID-19  and the result came out to be positive on 21st May and was self isolated since then. 

He developed dry cough 4 days back which was insidious in onset, intermittent in nature with no diurnal or positional variations . 

Then he developed shortness of breath 4 days back (grade II) which was insidious in onset and gradually progressive .

Since 2 days the patient started experiencing SOB grade IV ( NYHA ) so he went to an outside hospital for treatment. The HRCT chest report interpreted severe viral interstitial pneumonia with a severity score of 18/25 and CORADS-5. So he was advised to get treated in the present hospital .

He also had body pains and loss of smell and taste . 

No complaints  of headache, chest pain, diarrhea, cold, sore throat.

PAST HISTORY:

Not a K/C/O Diabetes Mellitus, hypertension, asthma, TB, epilepsy.

PERSONAL HISTORY :

Diet: Mixed

Appetite: Normal

Sleep: adequate

Bowel and bladder movements: Regular

Addictions: Occasionally drinks alcohol ( 3-4 times in a month , 90ml each time)

No known allergies

FAMILY HISTORY :

The patient's family members including his wife and child all tested positive for COVID-19.

GENERAL EXAMINATION:

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

Patient was conscious, coherent and cooperative, well oriented to time, place and person. 

• Pallor : Absent
• Icterus: Absent
• Cyanosis: Absent
• Clubbing: Absent
• Lymphadenopathy : Absent
• Edema : Absent

VITALS :

At the time of admission:

• Temperature : Afebrile       
• BP -120/80mmhg 
• PR- 72/min
• Spo2- 78% on RA 

  On 31/5/21: 

• Temperature - Afebrile
• BP : 120/80 mm/Hg
• PR: 70/min
• SpO2 : 90% on 15L of NRBM

On 1/6/21:

• Temperature : Afebrile
• Pulse rate : 60 cycles/min
• Blood pressure : 120/80 mmHg
• SpO2: 89% on 15L NRBM

SYSTEMIC EXAMINATION :

CVS : S1 and S2 heard

           No added thrills and murmurs

RS : Normal vesicular breath sounds heard,  BAE +

PER ABDOMEN : soft, non-tender

CNS: HMF normal

LAB INVESTIGATIONS :

HEMOGRAM :

• Hemoglobin: 14.8
• TLC : 6,400
• PLT: 2.15L

1/6/21

• Hb: 16.4
• TLC: 9,200
• PLT: 2.84 

LFT:

• Total Bilirubin - 0.98mg/dl
• Direct Bilirubin - 0.21mg/dl
• AST - 51 IU/L
• ALT - 43 IU/L
• ALP - 177 IU/L
• Total Proteins - 5.7 gm/dl
• Albumin - 3.0 gm/dl
• A/G - 1.14

RFT :

• Urea - 26 mg/dl
• Creatinine -1.0mg/dl
• Uric Acid- 4.2 mg/dl
• Ca+2 - 10.0mg/dl
• PO4 - 3.9 mg/dl
• Na+ - 138 mEq/L
• K+ - 4.1mEq/L
• Cl- 99 mEq/L

LDH : 513

ESR : 60

D.DIMER : 10

CRP : +ve (1.2) 

FERRITIN : > 1500

CT SCAN : ( Taken on 29/5/21 ) 

SEVERITY SCORE : 18/25

CORADS : 5

         ECG :

DIAGNOSIS : SARS COVID-19 VIRAL PNEUMONIA

TREATMENT:

 1. O2 inhalation to maintain SpO2>92%

 2. Intermittent BiPAP if dyspnoea increases 

 3. INJ. DEXAMETHASONE 6mg IV OD (D4)

 4. INJ. CLEXANE 40mg PO OD (D4)

 5. TAB. PANTOP  40mg PO OD

 6. TAB. MVT PO OD

 7. TAB. LIMCEE PO OD

 8. TAB. DOLO 650mg PO TID

 9. SYP. GRILLINCTUS 2tbsp TID

 10. GRBS at 8 am 

 11. BP /SpO2/ PR/ RR hourly 

 12. Monitor vitals