A Case of COVID 19 Pneumonia

 Introduction :  

This is 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 patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.

Regards to Dr. Anjali who has guided me and provided me with the information about the patient.

An Outline about the Patient : 

He is a 51 year old gentleman from a village in South India.

Chief Complaints : The Patient presented on 1/06/2021 with Cough since 6 days , Chest Pain since 4 days

History of Presenting Illness :  

The patient was apparently asymptomatic 6 days back when he developed Cough ( wet )  .It was insideous in onset . The expectoration was minimal in amount , mucoid in consistency , non foul smelling , non blood stained . Not aggravated or relieved with posture.

He developed Chest pain 4 days back , sharp in nature , not radiating to back , or upper limb . Pain aggravated on respiration movements of the chest and on coughing as well , no relieving factors as such.

COVID RTPCR done at the hospital on 3/6/21 and  positive results obtained.

There is no History of 

Shortness of Breath

Hemoptysis

Fever

Body Pains

Fatigue

PAST HISTORY :

  History of  previous infection with COVID 19 on 13/05/21 , for which he had been hospitalized and was given O2 Support for 5 days before his discharge on the 6th Day.

He is a K/C/O  DM, ( Since 9 years , takes Glimiperide 2mg , Metformin 500 mg BD )

HTN ( Since 3 years , takes Amlodipine 5 mg O.D )

No past H/o CAD , Asthma , Epilepsy .

PERSONAL HISTORY :

He has normal appetite ,

Takes Mixed Diet

Sleep slightly disturbed due to Cough 

Constipation since the last 5 days.

Not an alcoholic.

Used to Smoke but stopped 12 years back. 

No known Allergies.

Family History : 

Contacts being traced for any COVID  infected indivual ( if any ). 

GENERAL EXAMINATION : 

Done after obtaining consent , in a well lit room , in the presence of an attendant , with adequate exposure .

No pallor , Icterus , Cyanosis , Clubbing , Koilonychia , Generalised Lymphadenopathy or Pedal Edema.

 

VITALS  : 

RADIOLOGICAL INVESTIGATIONS : 

ECG :

REPORTS :  

MONITOR READING :  

PROVISIONAL DIAGNOSIS :

UPDATE :
7/JUNE/2021

Patient Discharged