28 year old man presenting with symptoms of COVID 19

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' 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 of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.

 
I have been given the following case to solve, in an attempt to understand  the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings,  Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

 CHIEF COMPLAINT

The patient came to the casualty with the complaints of

1. Fever since one day.

2. Body pain since one day.

3. Headache and giddiness.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 1 day back and then developed fever- gradual onset, body pains and headache and giddiness.

HISTORY OF PAST ILLNESS

No history of DM, Hypertension, Epilepsy and Tuberculosis.

FAMILY HISTORY

No significant family history .

GENERAL EXAMINATION

Patient is conscious and cooperative 

No pallor, icterus, cyanosis, clubbing , and edema.

No generalised lymphadenopathy.

VITALS AT ADMISSION 

Temperature -100 degrees fahrenheit

Pulse- 104 bpm

BP- 110/70 mmHg

Respiratory rate- 24 cpm

SpO2- 98%

SYSTEMIC EXAMINATION

CVS - 

S1 S2 heard

no thrills and murmurs

RESPIRATORY-

No DYSPNOEA or WHEEZING

Position of trachea - CENTRAL

Vesicular breath sounds heard.

CNS-

Patient is conscious and alert .

Speech is normal .

No neck stiffness.

Kernig's test - NEGATIVE

                       Rt              Lt

Reflexes- B      +               + 

                T       +              + 

                S      +                + 

                K     +   +           +  + 

                A      +                + 

                P      +                 + 

CEREBRAL SIGNS-

Finger nose test in coordination- YES

Knee- Heel in coordination - YES

  

PER ABDOMEN 

Soft , Non tender

No organomegaly

PROBABLE DIAGNOSIS

FEVER UNDER EVALUATION 

?VIRAL PNEUMONIA( RTPCR for COVID 19 POSITIVE )

INVESTIGATIONS ORDERED

CBP

CHEST X-RAY

TREATMENT

1. INJ. NEOMOL

2. INJ. NS 100ml /Hr

3. INJ. TRAMADOL 1 Amp in 100 ml IV

REFERRED TO -

BRIEF HISTORY DIAGNOSIS- 

Patient came with c/o fever since 1 day.

REASON FOR REFERRED-

RT PCR for COVID 19 POSITIVE 

Referred to COVID centre.

DISCHARGE SUMMARY 

NAME OF TREATING FACULTY- 

DR. MADHUMITA (INTERN)

DR. CHITRA (INTERN)

DR. KAVYA (INTERN)

DR. HARSHINI (INTERN)

DR. SWAROOPA (INTERN)

DR. PRADEEP (PGY1)

DR. AJITH (PGY2)

DR. ZAIN ALAM (PGY2)

DR. HAREEN(SR)

DR. RAKESH BISWAS (HOD)

DIAGNOSIS

?VIRAL PNEUMONIA

RTPCR FOR COVID 19 IS POSITIVE

CASE HISTORY AND CLINICAL FINDINGS 

28/M came to casualty with complaints of fever since 1 day and generalised weakness since 1 day.

Patient gives history of exposure to COVID 19 POSITIVE patient.

O/E

VITALS-

PR- 84 BPM

BP- 120/90 mmHg

CVS- S1, S2 +

RS- BAE +

CNS- NFAD

P/A- SOFT . Nontender

INVESTIGATIONS

ECG - NORMAL 

TREATMENT GIVEN

1. INJ. NEOMOL IV/ STAT

2. INJ. NS 100ml /Hr

3. INJ. TRAMADOL 1 Amp in 100 ml IV/STAT

ADVICE AT DISCHARGE

PATIENT'S ATTENDERS HAVE BEEN EXPLAINED ABOUT THE PATIENT , RTPCR FOR COVID 19 IS POSITIVE , SO PATIENT IS BEING REFERRED TO THE COVID CENTRE.

WHEN TO OBTAIN URGENT CARE

INCASE OF ANY EMERGENCY IMMEDIATELYY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

PREVENTIVE CARE

AVOID SELF MEDICATION WITHOUT DOCTORS' ADVICE, DO NOT MISS MEDICATIONS.

DATE OF DISCHARGE- 21.7.2021