a patient with fever cough for 5 days & breathlessness for 3 day

1. Welcome to our weekly case
presentation session
Chairperson: Prof. Dr. Faruk Ahammad
(Head of the department, Internal Medicine, CMMC)
Venue: Conference room (2nd floor) 250 bedded General Hospital, Manikganj
Date: 6th January 2021
Time: 11:30 AM

2. Topic: A 65 years old man with
fever & breathlessness
Speaker:
Dr. Md. Ahsan Kabir
(Intern Doctor, CMMCH)
Co-ordinator:
Dr. Motahar Hossain
(Associate professor,
Internal Medicine, CMMCH)

3.  Name: Md. Jonab Ali
 Age: 65 years
 Gender: Male
 Religion: Muslim
 Marital status: Married
 Occupation: Tailor
 Address: Shibaloy, Manikganj
 Date of admission: 25th December 2020 @ 11:30 AM
 Date of examination: 26th December 2020 @9:30AM
Particulars of the patient

4.  Fever for 5 days
 Cough for 5 days
 Breathlessness for 3 days
Chief Complaints

5.  According to the statement of the patient, he was
reasonably well 5 days back. Since then, he has been
suffering from fever. Highest recorded temperature is
102ºF. Fever is partially relieved by taking Paracetamol.
There is no diurnal variation, not associated with chills and
rigor, unconsciousness, neck rigidity, night sweat & rash.
History of present illness
The patient also complains of cough for 5 days which is
non productive. Cough is present throughout the day and
night.

6. History of present illness (cont.)
 He also complains of difficulty in breathing for 3 days,
more marked during exertion and relieved by taking
oxygen. There is no history of chest pain, hemoptysis,
orthopnea, paroxysmal nocturnal dyspnea, swelling of leg
and weight loss.
 On query, The patient complains of loss of appetite & loss
of sense of smell. He is normotensive and diabetic which
is controlled by taking medication. His bowel and bladder
habits are normal.

7. History of past illness
 The patient is a known case of bronchial asthma from
his childhood which is aggravated in winter season and
controlled by taking medications.

8. Family history:
 His brother is suffering from bronchial asthma and other
family members are in good health.
Personal history:
 Patient is non smoker & non alcoholic .
Socio economic history
 Patient comes from a middle class family. He lives in brick
built house & uses sanitary latrine and drinks tubewell water.

9. Immunization history
Patient was not immunized under EPI schedule.
Travelling history
No history of travelling to hilly areas
Drug history
o Tab. Metformin+ Linagliptin 5/500mg (0+0+1)
o Tab. Gliclazide 80mg (1+0+0)
o Inh. Salbutamol ( 2 puffs TDS)
o Inh. Salmeterol+ Fluticasone ( 2 puffs TDS)
o Tab. Montelukast 10mg (0+0+1)
o Tab. Doxofylline 200mg (1+0+1)
o Tab. Paracetamol 500mg (1+1+1)

10. General examination
 Appearance: Dyspneic
 Body built: Average
 Decubitus: On choice
 Nutritional status: Average
 Co-operation: Well co-operative
 Anemia: Absent
 Jaundice: Absent
 Cyanosis: Absent
 Clubbing: Absent
 Koilonychia: Absent
 Leukonychia: Absent

11. General examination (cont.)
 JVP: Not raised
 Edema: Absent
 Dehydration: Absent
 Bony tenderness: Absent
 Thyroid gland: Not palpable
 Lymph nodes: Not palpable
 Skin condition: Normal
 Pulse: 110 bpm
 Blood pressure: 120/70 mm(Hg)
 Temperature: 101 ºF
 Respiratory rate: 26 breaths/min

12. Respiratory system examination
 Inspection:
Shape of the chest: Normal
Movement of the chest: Restricted on right side
Respiratory rate: 26 breaths/min
 Palpation:
Trachea: Central in position
Apex beat: In the left fifth intercostal space medial to the
midclavicular line normal character

13. Respiratory system examination (cont.)
 Percussion:
Percussion note: Woody dull over lower part of right lung.
Upper border liver dullness is in right 5th ICS in MCL.
 Auscultation:
Crepitation present in both side of lungs

14. Cranial Nerve examination
On examination of cranial nerve,
function of olfactory nerve is impaired.

15. Other systemic examination reveals no abnormality

16. Salient feature

17. My patient Md. Jonab Ali 65 years old male muslim married
tailor normotensive, diabetic hailing from Shibaloy,
Manikganj was admitted in Manikganj Sadar Hospital with
the complaints of fever and cough for 5 days,
breathlessness for 3 days.
Highest recorded temperature is 102ºF. Fever is partially
relieved by taking Paracetamol. There is no diurnal
variation, not associated with chills and rigor,
unconsciousness, neck rigidity,night sweat & rash. The
patient also complains of cough which is non productive.
Cough is present throughout the day and night.
Salient feature

18.  On query, The patient complains of loss of appetite & loss
of sense of smell. He is normotensive and diabetic which
is controlled by taking medication. His bowel and bladder
habits are normal. The patient is a known case of
bronchial asthma from his childhood which is aggravated
in winter season and controlled by taking medication.
Salient feature (cont.)
 He also complains of difficulty in breathing, more
marked during exertion and relieved by taking oxygen.
There is no history of chest pain, coughing out of blood,
breathlessness on lying flat, waking up from sleep due
to beathlessness, swelling of leg and weight loss.

19. Salient feature (cont.)
On general examination patient is dyspneic, average
body built, co-operative. JVP is not raised. Edema,
dehydration are absent. Skin condition is normal. Pulse is
110 b/min, blood pressure is 120/70 mm(Hg),
temperature is 101ºF.

20. Salient feature (cont.)
On respiratory system examination shape of the chest is
normal. Movement of the chest is bilaterally restricted.
Percussion note: Woody dull over lower part of right lung.
Upper border liver dullness is in right 5th ICS in MCL.
Bronchial breath sound in lower part of right lung. Vocal
resonance is increased over the mentioned area
On examination of cranial nerve, function of olfactory nerve
is impaired.

21. Provisional Diagnosis
?

22. My provisional diagnosis
Pneumonic consolidation
with bronchial asthma with
Diabetes Mellitus

23. Differential Diagnosis
 Acute severe asthma
 Diabetic ketoacidosis

24. Investigations

25. Hematological report
Hemoglobin: 14.2 gm/dl
ESR: 20 mm in 1st hour
TC of WBC: 9290 /cmm
Neutrophil: 80%
Lymphocyte: 10%
Platelet count: 282000cmm

26. CRP: positive

27. Urine RME: Normal

28. Random blood sugar:
13 mmol/l

30. CXR PA view
Impression:
Bilateral consolidation
more at right side

31. Lab report
RT PCR for COVID 19:
Positive

32. HRCT OF
CHEST

35. Impression:
Covid-19
pneumonitis
CT scan report

36. COVID 19 pneumonitis
With
Diabetes Mellitus
Final Diagnosis

37. Investigations to evaluate
prognosis

38. Prothombin time:
17 seconds

39. Serum Calcium:
Normal

40. Serum bilirubin: normal
SGPT: 96 U/L
SGOT: 63 U/L

41. Electrolyte report
Serum sodium: 134 mmol/l
Serum chloride: 103 mmol/l
Serum potassium: 3.7 mmol/l

42. D-dimer
0.39 mg/l

43. S. Ferritin: 587.29
ng/ml
S. LDH: 595 U/L
Magnesium: 2.52
mg/dl

44. FBS: 10.7 mmol/l
2 HABF: 14.8
mmol/l

45. Serum Troponin I:
Normal

46. Serum creatinine:
1.4 mg/dl

47. Range of SpO2 from 25th
December to 31st December
2020
93% to 97%

48. Rx

49.  Diet diabetic
 Oxygen inhalation 4L/min
 Inj. Ceftriaxone 1gm
1 vial IV BD
 Inj. Enoxaparin 40 mg
1 PFS SC BD
 Inj. Dexamethasone 5mg/ml
1 amp. IV TDS
 Tab. Favipiravir 200mg
3+0+3
 Tab. Baricitinib 2mg
0+0+2
 Tab. Zinc Sulfate 20mg
1+0+1

50.  Tab. Glimepiride 1mg
1+0+0
 Tab. Vildagliptin+ Metformin 50/500mg
0+0+1
 Tab. Doxofylline 200 mg
1+0+1
 Tab. Montelukast 10 mg
0+0+1

51. Follow up on 5th January 2021
Respiratory rate 18 breaths per minute
Oxygen saturation 98%
Temperature 99ºF
Pulse: 82 b/m
Bp: 130/70 mm(hg)
Sense of smell improved
Appetite is also improving
Patients general condition is improving