51 year old with COVID PNEUMONIA
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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.
Pt c/c/c
Bp: 130/90 mmhg
PR: 96/min
SpO2: 98%
RR: 22/min
Temp: 97.5F
GRBS: 334mg/dl
CBP:
Hb: 10.2
TLC : 12,200
PLT: 2.77
5/06/2021
Bp: 120/90 mmhg
PR: 92/min
SpO2: 98%
RR: 22/min
Temp: 97.5F
GRBS: 327mg/dl
6/06/2021
Bp: 120/90 mmhg
PR: 96/min
SpO2: 98%
RR: 20/min
Temp: 97.5F
GRBS: 312mg/dl
RADIOLOGICAL INVESTIGATIONS :
PROVISIONAL DIAGNOSIS :
UPDATE :
7/JUNE/2021
Patient Discharged
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