Covid pneumonia in a pre existing case of interstitial lung disease

 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 58-year-old female presented with the chief complaints of fever for 6 days, and shortness of breath for 2 days.

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 6 days ago (14th May 2021) when she developed a fever with chills, sudden in onset and continuous in nature, with no associated rigors. She complained of a dry cough that was insidious in onset and intermittent in nature, with no diurnal or positional variations. No aggravating or relieving factors were noted.  She also noticed a diminution in her sense of smell and taste on the same day

14th May 2021:Patient's home pulse oximeter reading showed an O2 saturation of 87% upon seeing which her family took her to the nearest hospital#1 where the diagnosis of Covid-19 was made clinically based on her symptoms. Here she was prescribed paracetamol and an antibiotic. The patient adhered to this treatment for the next 4 days.

17th May,2021:As her symptoms did not get any better, she was taken to Hospital#2 where her SpO2 at RA was 92%. Here, she tested positive for COVID via RTPCR on 17th May 2021. She was apparently asked to continue the previous treatment in addition to which she was prescribed multivitamins and an antitussive.
The patient started practicing proning at home.

19th May, 2021:At this point, her fever still hadn't subsided and her home pulse oximetry showed a reading of 90%. The patient also started complaining of shortness of breath on exertion(mMRC grade 1). On account of her pre-existing lung disease, the patient's family decided to be cautious and get her admitted to hospital#2. 
She was prescribed the current treatment plan and was given O2 inhalation with intermittent BiPAP. 
An HRCT of the chest showed CT severity index: 16/25 and CORADS 6.

(Note: Patient's family claims that SpO2 in the ranges of 90-92% has been the norm for their mother for the past 6 years since the diagnosis of her interstitial lung disease) 

20th May 2021: At present, the patient's attender claims that her cough has subsided. She is said to have a fever with malaise.

No history of headache, vomiting, diarrhea, sore throat, myalgia, or chest pain.
No history of cardiovascular accidents.

PAST HISTORY

No history of prior covid infection

The patient has not been vaccinated

History of interstitial lung disease for the past 6 years: It was first diagnosed in 2015 and is said to have rapidly progressed in the span of a year. In 2016 she was intubated for mechanical ventilation(duration unknown) during her stay at a local hospital X

History of hypothyroidism and Rheumatoid Arthritis since the past 5 years

Known case of DM-2 (duration unknown)

Not a known case of Hypertension, recovered/active TB, or Epilepsy.

PERSONAL HISTORY

• Diet: Mixed
• Appetite: Normal
• Sleep: Normal
• Bowel, bladder: Regular
• Addictions: None

DRUG HISTORY

• Takes levothyroxine supplement for her hypothyroidism and oral anti glycemic(unknown) for DM2
  
• Took 200mg of unknown antibiotic for 4 days before arriving at hospital#2
• No known drug allergies. 

FAMILY HISTORY

Her son has tested positive for Covid-19. Her husband and remaining family members have tested negative.

No family history of Diabetes Mellitus, Tuberculosis, Epilepsy, Hypertension

No history of Autoimmune disease (RA, hypothyroidism, psoriasis) in the family prior to the patient

GENERAL EXAMINATION (at the time of admission)

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

• The patient is conscious, coherent, cooperative
• She is well oriented to the day, time, place, and person

1. Pallor: Absent
2. Icterus: Absent
3. Cyanosis: Absent
4. Clubbing: Absent
5. Lymphadenopathy: Absent
6. Edema: Absent 

Vitals: (at time of admission)

• HR: 102bpm
• BP: 110/70mmHg
• RR: 22cpm 
• Temp: 100°F
• SpO2: 93% at RA 
             96% at 5lit O2

SYSTEMIC EXAMINATION (at time of admission):

• Respiratory System: Bilateral air entry positive
• CVS: s1, s2 heard
• CNS: Normal
  
  
  
  
  
  
  
  
  No visible involvement of MCP or PIP joints
  
  
  

               Minimal wrist joint involvement
            showing that RA is inactive

INVESTIGATIONS 

1) HRCT of the thorax: 

Findings: CTSI-16/25, CORADS 6 (19/05/2021)

2) HbA1c

3) ESR (Westergren) 

PROVISIONAL DIAGNOSIS

Viral pneumonia secondary to COVID-19 infection, overlapping Interstitial lung disease.

TREATMENT REGIMEN:

• Prone positioning
• O2 inhalation with Intermittent BIPAP
• DUOLIN BUDECORT nebulization 
• Inj. DEXAMETHASONE 8mg IV OD
• Inj. REMEDISVIR 100mg IV OD
• Inj.PANTOP 40mg iv od
• Inj.CLEXANE 60mg/sc /OD
• Tab. THYRONORM 75ug 
• Tab. HCQ 100mg/ OD
• Tab. LIMCEE od
• Tab. Multivitamin OD
• Tab. PARACETAMOL SOS
• Syrup GRILLINCTUS 10ml OD