A 23 Year Old Female With Sore Throat

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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


2. C Reactive Protein


3. D-Dimer


4. Renal Function Test



5. Blood Sugar - Random



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









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