Viral pneumonia secondary to COVID 19

 June 10th, 2021



This is an online blog sharing 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-centred online learning portfolio and your valuable comments on comment box is welcome. 


 Name : Prasuna, roll no. 49

 8th semester 


Following details were  provided to me by Intern Dr Anjali ma'am.


 Case details


A 45 year old male has presented with the casuality with the chief complaints of sudden onset shortness of breath on 2nd June 2021


History of presenting illness


The patient was apparently asymptomatic till June 2nd .

Then he developed grade 4 SOB which is of sudden onset.

There was a history of orthopnea

No history of fever, cough, cold, sore throat, loss of appetite, chest pain, palpitations, giddiness, sweating, blurring of visions, blackout


Based on the above history he was sent for rapid antigen test for covid-19 which he was tested positive on 2nd June 2021 and then he was admitted in COVID ICU 



History of past illness

No history of diabetes hypertension tuberculosis or epilepsy


Personal history 

Appetite : normal

Diet : mixed

Bowel and bladder habits: regular

Sleep : adequate

Addictions: No addictions


No history of drug and food allergies


Family history: not significant


General examination 

The patient is conscious for rent in cooperative

He is well oriented to time place and person

Moderately built and moderately nourished


Pallor: absent

Icterus:absent

Cyanosis:abent

Clubbing:absent

Lymphadenopathy: absent

Edema: absent 


Vitals

Temperature: afebrle

Pulse:  132bpm

Respiratory rate:33cpm

Blood pressure: 90/60 mmHg

SPO2:91 on room air

GRBS:100mg%



Systemic examination:


Cardiovascular system: s1 s2 heard,  No thrills and murmurs

Respiratory system;

• DYSPNEA ; PRESENT

• BILATERAL CREPTS 

Abdomen: SOFT and NON TENDER


CNS:  Normal 


Provisional diagnosis: VIRAL PNEUMONIA SECONDARY TO COVID -19 


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