CASE OF COVID-19

M.SNEHA
ROLL NO-74

NOTE
  • The following online e-log  aims at discussing our patients de-identified health data shared after taking the consent.
  • I have been given this case to understand patients clinical data analysis to develop my skills in providing the treatment and diagnosis based on the history,investigations and clinical findings.
  • This E-log is made under the guidance of Dr.kranthi mam.

A 23 year old female [student] came to the OPD with the chief complaints of 

» Body pains from 3 days
» Sore throat past 3 days
» Loss of smell from 3 days
» Cold past 2 days
» Headache from yesterday

History of present illness :

» Patient was asmptomatic 3 days back
» Low graded fever from morning,2 hours subsided on medication
» No chills and rigor 
» She had exposure to COVID-19 contact

History of past illness :

» No C/O shortness of breath / PND
» No C/O chest pain / palpitations / syncopal attack
» No C/O of burning micturition
» No C/O nausea / loose stools / constipation / vomitting
» Anosmia +ve

Treatment history

» No significant drug history

Personal history :

» Appetite - Normal
» Non Vegetarian
» Micturition - Normal
» Habits : Non smoker , No drug , pan use

Family history :

» No Diabetes
» No hypertension
» No Cardiac diseases
» No TB,  asthma

Allergic history :

» No significant allergic history

GENERAL EXAMINATION :

» No Pallor
» No Icterus
» No Cyanosis
» No Clubbing
» No Lymphadenopathy
» No Edema of feet

Vitals :

» Pulse rate - 92 bpm
» Respiartory rate - 20 per min

SYSTEMIC EXAMINATION

Cardiovascular system :

» No thrills
» No Cardiac murmurs

Respiratory system :

» No Dyspnoea
» No Wheeze
» Position of trachea - Central
» Vescicular breathing sounds

Abdomen :

» Shape of abdomen - Scaphoid
» No tenderness
» No Palpable mass
» Hernial Orifices - Normal
» No Free fluid
» No Bruits
» Liver - Not palpable
» Spleen - Non palpable
» Bowel sounds - No
» No Abnormalities detected in Genitals , Speculum examination , PV examination , P/R examination

Central Nervous System :

» Concious and coherent

Reflexes :

 

Right

Left

Biceps

+

+

Triceps

+

+

Supinator

+

+

Knee

+

+

Ankle

+

+

Plantars

Flexor

Flexor

Cerebral Signs :

» No finger nose incordination
» No Knee heal incordination

INVESTIGATIONS :

RT-PCR TEST POSITIVE

CBP -


HAEMOGRAM -


RENAL FUNCTION TEST [RFT] -



D-DIMER TEST -


RANDOM BLOOD SUGAR -


COMPLETE URINE EXAMINATION -




PROVISIONAL DIAGNOSIS :

COVID-19 FEVER

TREATMENT :

  • TAB PCM 650 mg PO/TLD
  • INJ NEOMOL 1 g / IV [ TEMP>101 F]
  • TAB CETIRIZINE 5mg PO/OD
  • SYP BENADRYL 5 ml PO/TLD
  • TAB PAN 40 mg PO/OD
  • TAB AZYTHRO 500 mg PO/OD
  • TAB ZINCOVIT PO/OD 30 DAYS
  • BP/PR/RR/SPO2 CHARTING EVERY 4TH HOUR
  • TEMPERATURE CHARTING



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