This is a case of a 50 years old male, Yakan, from Talon-talon with a chief complaint of

difficulty of breathing.

I. History of Present Illness:

1 week prior to admission, the patient had a sudden onset of intermittent fever,
undocumented through palpation associated with loss of appetite, dry cough and colds. There
was no consultation done. Self medicated with Paracetamol 500mg/tab 1 tab as needed for fever
and Solmux tablet 1 tab, three times a day. 1 day prior to admission, there was persistence of
signs and symptoms associated with minimal dyspnea. Still, there was no consult done. Few
hours prior to admission, the patient noted severe dyspnea hence consult and admitted.

II. Past Medical History

a. Childhood Illnesses: Unrecalled previous infection/s.
b. Medical: No previous hospitalization.
c. Surgery: No previous surgery.
d. Allergies: No known allergies to any food and drugs.
e. Medications: No medications were taken.
f. Immunization: Unknown immunization status.

III. Family History

a. (-) Hypertension
b. (-) Kidney disease
c. (-) Diabetes Mellitus
d. (-) Cardiac disease
e. (-) Asthma
f. (-) Cancer

IV. Personal and Social History

a. Diet consists of vegetables, chicken, fish and rice
b. Nonsmoker
c. Non-alcoholic drinker
d. Denies illicit drug use

V. Review of Systems
a. General: (+) weight loss, (+) fever, (-) easy fatigability, (+) body
weakness, (-) body malaise
b. Skin: (-) pallor, (-) rash, (-) lumps, (-) itching, (-) jaundice
c. HEENT:
i. Head: (-) dizziness, (-) headache, (-) lightheadedness
ii. Eyes: (-) pain, (-) blurring of vision, (-) redness, (-) excessive tearing
iii. Ears: (-) ear pain, (-) tinnitus, (-) hearing difficulties
iv. Nose: (-) colds, (-) epistaxis
v. Mouth and Throat: (-) dysphagia, (-) odynophagia, (-) hoarseness,
(-) bleeding gums,
d. Respiratory: (+) cough, (+) DOB, (-) chest tightness, (-) hemoptysis,
(-) pleurisy
 e. Cardiovascular: (-) chest pain, (-) palpitations,
(-) orthopnea
f. Gastrointestinal: (+) anorexia, (-) nausea, (-) vomiting,
(-) change in bowel habits and stool caliber, (-) constipation,
(-) diarrhea
g. Genito-Urinary: (-) oliguria, (-) dysuria, (-) nocturia, (-) hematuria, (-) polyuria
h. Hematologic: (-) easy brusing, (-) bleeding, (-) pallor

VI. Physical Examination

a. General appearance:
b. Patient was seen sitting on bed, awake, and responsive. Oriented to three spheres
(time, person, and place) and in respiratory distress.

c. Vital Signs:
i. Blood pressure: 110/70
ii. Respiratory rate: 32 cpm
iii. Temperature: 38°C
iv. Pulse rate: 80 bpm
v. O2 sat: 90% at room air
vi. Weight: 55 kg
d. Skin: (-) pallor; (-) dry skin; (-) rashes on trunk and extremities
e. HEENT:
i. Head: No scars and lesions; No facial edema
ii. Eyes: Anicteric sclerae; pink palpebral conjunctiva; pupils equally round
and reactive to light
iii. Ears: No lesion; No discharges; Both pinna symmetrical
iv. Nose: Septum midline; no nasal flaring noted; normal sinus; no masses or
tenderness
v. Throat: No mouth sores; No dryness of the oral mucosa; No bleeding
f. Thorax and Lungs:
i. Inspection: Equal chest expansion
ii. Auscultation: (+) crackles on bilateral lung fields
g. Abdomen:
i. Inspection: flat
ii. Palpation: soft, nontender
iii. Auscultation: normoactive bowel sounds
h. Extremities:
i. No edema
ii. No clubbing of fingers;
iii. No varicosities;
iv. Capillary refill time < 2sec
i. Neurologic:
i. GCS 15 (E4, V5, M6)
ii. Patient is alert, awake and cooperative.
iii. Oriented to person, time and place.
iv. Obeys command and answers questions
 VII. Admitting Diagnosis
a. Covid suspect with Community Acquired Pneumonia Moderate Risk

VIII. Doctor’s Orders:

 Please admit to covid ward

 Secure consent
 VS q4
 DAT
 Labs:
 CBC,BT
 UA
 RT-PCR
 CXR(PA)
 FBS
 LIPID PROFILE
 Serum Crea, Na, K
 12 lead ECG
 IVF: PNSS 1L at 20gtts/min
 Meds:
o Paracetamol 300mg ivtt q4 for temp >38*c
o Ceftriaxone 2gms ivtt now then q12 ()anst
o Azithromycin 500mg PO OD x 5days
o Levocetirizine+Montelukast tab PO OD HS x 1wk
o Salbutamol inhaler 2 puffs BID PRN for DOB
o Vit C + Zinc tab PO OD
 Hook to 02 via NC at 3LPM
 Maintain on high back rest
 Refer Accordingly

Attending Physician: Lourdes Ursula O De Villa, MD MPH

Medical Officer III