COVID-19 PNEUMONIA

Vana Mounika
3rd sem, roll no 140

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.
I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings, investigations, and come up with a diagnosis and treatment plan.
CASE SCENARIO :
A 63 year old patient came to casuality with chief complaints of shortness of breath since 3 days, fever intermittent in nature associated with chills .
HISTORY OF PRESENT ILLNESS:
Patient was asymptomatic 15 days back when he developed fever and generalised weakness, patient experienced SOB since 3 days .
Outside HRCT - 11/ 25
HISTORY OF PAST ILLNESS:
N/K/C/O - HTN and DM
TREATMENT HISTORY :
No usage of drug as now 
PERSONAL HISTORY:
Married 
OCCUPATION - Farmer 
Appetite - Normal 
Non vegetarian
Bowels - Regular
Micturition - normal
No known allergies
Occasional alcohol
FAMILY HISTORY :
NAD
GENERAL EXAMINATION :
No pallor 
No icterus
No cyanosis
No clubbing
No kolionychia
No lymphadenopathy
No edema 
No malnutrition
No dehydration
VITALS :
Temp- afebrile c/f
Pulse rate - 129bpm
Respiratory rate - 22cpm
BP - 90/60 mmHg
SPO2 - 80 %
GRBS : high
SYSTEMATIC EXAMINATION :
CVS :

No Thrills
Cardiac Sounds - S1, S2 +
No cardiac murmurs
Respiratory :
BAE (bronchial artery embolization )+
Dyspnea yes 
Position of trachea - central
Adventia sounds- crepts 
ABDOMEN
shape -schapoid
Hernial orifice normal
No tenderness
No palpable mass
No free fluid 
No bruits
Liver not palpable
Spleen not palpable 
Bowel sounds - yes 
Genitals normal 
CNS
Level of consciousness - drowsiness
Speech normal
Signs of meningeal irritation - no
Cranial nerves intact 
No motor or sensory deficit
CEREBRAL SIGNS 
finger nose in- coordination - no
Heel knee in-coordination - no
Reasons for lack of coordination ???
Gait normal 
INVESTIGATIONS :



PROVISIONAL DIAGNOSIS :
COVID - 19
WHAT DOES CEREBRAL SIGNS INDICATE ???
TREATMENT :









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