85 year old male with Covid 19 pneumonia,AKI and atypical parkinsonism

MBBS 8th semester

Name:Rithika.K

Roll no: 69

 This is an 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.

Under the guidance of Dr.Divya Mahapatra, Dr.Anjali and Dr.Vinay 

CASE DISCUSSION

A 85 year old male who is a carpenter by occupation came to the opd with 

Chief complaints of SOB since 5 hours

History of present illness:

Patient was apparently asymptomatic one day back and then he developed SOB which was sudden in onset and progressive in nature and present even at rest (Grade 4) 

History of fever 5 days back which was high grade associated with chills and rigor 

Relieved on taking medication

He complaints of constipation since 2 to 3 months and pass the stool once every 4 to 5 days 

He had involuntary micturition on the day of admission at afternoon which was associated with pain 

He also had a history of involuntary micturition 2 years ago for which he had been treated by a local RMP

Memory loss since 1year 

He tested positive for covid 19 on 3rd June

History of past illness:

A known case of hypertension since 30 years 

A known case of dm since 7 years  

He was operated for gall bladder stones 10 years ago (cholecystectomy)

Personal history:

Appetite: decreased (since 1 month)

Diet:mixed

Sleep: excessive ( since few days)

Bowel: irregular Passed stools once in 4-5 days 

Micturition: abnormal ( involuntary micturition on the day of admission)

No known allergies

Addictions: Stopped alcohol consumption and beedi smoking 15 years ago

Family history: insignificant

Drug history :

Tab Telma for hypertension

Tab Glycomet for DM

Tab Clopitab since 2 years 

General physical examination:

The patient was examined in a well lit room 

Vitals on admission

Pulse rate: 117 bpm

Blood pressure: 110/80 mmHg 

Respiratory rate : 38 cpm

Temperature: 100.1 °F

Vitals on 03-06-2021:

Pulse rate: 95 bpm

Blood pressure: 100/60 mmHg 

Temperature: 98.7 °F

SPO2: 98%  with 12L of O2

Vitals On 04-06-2021

Systemic examination on 03-06-2021

CVS S1 and S2 heard

No cardiac murmurs

No thrills

Respiratory: 

normal vesicular breath sounds present

B/L wheeze present in IAA and ISA (L>R)

Dyspnea is present

B/L crepitus present

Per abdomen: 

Shape of abdomen: distended

diffuse tenderness is present 

No palpable mass 

Hernial orifices are normal

No free fluid present

Liver is not palpable

Spleen not palpable

Bowel sounds are heard 

CNS:

Level of consciousness: stuporous

Speech: no response

Signs of meningial irritation present:

    Neck stiffness present

    Kernings sign is postive

GCS: E2 V1 M4

Tone of muscles : increased in all four limbs 

                             Right    Left 

Power of muscle

Upper limb.          2/5.        2/5

Lower limb           2/5.        2/5

Reflexes

              B       T       S       A       K       P

Right.    3+     3+    3+    3+     3+     withdrawal

Left.       3+     3+    3+    3+     3+     withdrawal

Investigations:

ABG:

Complete blood picture:

Complete urine examination:

Renal function test:

 Hyperkalemia ( drug induced? ARB's?)

Liver function test:

ECG

Chest X-ray 

Left lower lobe consolidation present

MRI brain:

Diagnosis:

Covid 19 pneumonia with AKI ( pre renal cause)

Atypical Parkinsonism-MSA

Treatment:

 Day 1:(02-06-2021)

Tab METROGYL 100 ml / 1V / TID

Inj HYDROCORTISONE 100 mg IV stat

Inj TAZAR 4.5 gm IV stat followed by 4.5 gm IV TID

Tab. AZITHROMYCIN 500 mg OD

Day 2:(03-06-2021)

INJ AUGMENTIN 1.2 gm/ IV/BD

INJ PANTOP 40 mg/IV/OD

Nebulization with DUOLIN And BUDECORT 6th hourly

INJ HAI 8 U in 25% Deutrose / IV /stat 

Monitor GRBS 6th Hourly

INJ NEOMOL 1gm/IV/SOS (If temp > 101°F)

Tab. PCM 60mg

I/O – CHARTING

Temp Charting 6th Hourly and tepid sponging

IVF 0.9 % NS with 1 ampule optineuron @ 75 ml/ hr 

Day 3:(04-06-2021)

Inj -clexane 40 mg s/c OD

Inj Augmentin 1.2gm I/V BD

Inj Pan 40 mg I/V OD

Nebulization with DUOLIN And BUDECORT 6th hourly

Inj Dexa 8 mg I/V OD

Inj. Human Actrapid

Inj. Neomol 100 ml given 

Dialysis

Complications of dialysis:

Common causes:

1.Intradialytic hypotension

Systolic bp fall by > 20 mmHg within first 30 minutes of dialysis.

2.muscle cramps

3.Nausea and vomiting

4.Fever

Uncommon causes:

1.Dialysis disequilibrium syndrome( increase ICT and Cerebral oedema)

Seen in first dialysis

Prolonged dialysis and Increased ultrafiltration rate.

2.Dialyser reactions:

Type A:

Serious reactions due to ethylene oxide.

Severe chest pain

Cardiac arrest.

Type B:

Seen after 15-30 minutes.

Slight chest discomfort is present

3 Arrhythmias

4.air embolism

5.haemolysis

The patient passed away the following night