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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .
A 23 Year Old Female With Sore Throat
CHIEF COMPLAINT:
A 23 year old female presented with complaints of:
- sore throat since 3 days
- loss of smell since 2 days
- cold since 2 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 days back. The patient has been in contact with a COVID +ve person.
HISTORY OF PAST ILLNESS:
No History of Diabetes, Hypertension, TB, CAD or Asthma.
PERSONAL HISTORY:
Occupation: Student
Appetite: Normal
Diet: Mixed
Bowel movements: Regular
Micturition: Normal
No known allergies
Habits/Addictions: None
FAMILY HISTORY:
Not significant
PHYSICAL EXAMINATION:
- Mild pallor present
- No icterus
- No cyanosis, clubbing, edema or lymphadenopathy
Vitals:
- Pulse rate: 92/min
- Respiration rate: 24 breaths/min
- BP: 120/80 mmHg
- SpO2: 97%
PROVISIONAL DIAGNOSIS:
COVID-19. RTPCR +ve
INVESTIGATIONS:
1. Haemogram
TREATMENT:
10/7/21:
1. Tab. PCM 650mg PO/TID
2. Tab. PAN 40mg PO/TID @8 am
3. Inj. Neomol Ig/IV/SOS if temp.>101 F
4. Syrup Benadryl 5ml/PO/TID
5. Tab. Cetrizine 5mg PO/BD
6. BP/PR/RR/SpO2 charting 4th hourly
7. Tab. Azithro 500mg RO/OD
8. Temp. charting 2nd hourly
9. Tab. Zincovit PO/OD x 30 days
