Good morning doctors, consultants, residents, PGIs and fellow clerks.

Today is December 7,
2021. I am clerk espinosa and together with me are clerks arnaiz, brazas, deocadez and lee.
PGIs abello and dillera with our residents-in-charge dr. Amsicua, dr, dela cruz and dr. Merado

Today, we have 0 admissions, 0 referrals, 0 discharged, 0 morbidity with a total census of 3

We are given an OPD case of P.J. a 29 year old male from Oton, Iloilo with a chief complaint of
cough
3 days prior to consultation, the patient experienced a productive cough with whitish phelgm
associated with nasal catarrh. He had no fever, loss of smell and taste, sore throat, throat
itchiness, difficulty of breathing, anorexia, and GI losses. He also had no history of exposure to
covid (+) patients and no recent travel to areas with reported outbreak. No consultation and
medications were taken

The night prior to consultation, the patient had on and off dull back pain on the left upper area,
observed during coughing with a pain scale of 5/10. There was also persistence of cough and
nasal catarrh. No consultation and medications were taken

On the day of consultation, these symptoms persisted; hence, the patient decided to seek
medical advise. Thus, this consultation.

We now go on the risk factors. The following are DOH case definitions taken from the PISMID
guidelines

Suspect case – is a person who is presenting with any of the conditions below:
- influenzalike illness (ILI) and severe acute respiratory infection (SARI) -
Probable case – a suspect case who fulfills anyone of the following listed below.
Confirmed case (read)
Contact (read)

With these, we label our patient as a COVID-19 suspect. However, please go back 2 slides
before. As you can see here, the only criteria that we partially met was criteria B and C but with
no travel history to areas reported of having local outbreak, no contact with COVID-19 (+)
patients, no comorbidity, not a healthcare worker and is only 29 years old.
However, we base our clinical judgement on the fact that patient P.J. presents with respiratory
symptoms during COVID-19 pandemic. Now, this warrants further investigation hence the
decision to label this patient as a COVID-19 suspect.

Next would be some of the differential diagnoses to consider in a COVID-19 patient. First, we
have the 3 most frequent: the CAP, pulmonary tuberculosis and influenza as was discussed
previously and less frequently are pneumocystis jirovecci pneumonia in patients who are
usually immunocompromised (e.g., HIV positive), CD4 count of < 200 and a longer duration of
symptoms
and febrile neutropenia in patients with a history of recent systemic anticancer treatment who
present with fever (with or without respiratory symptoms).

P.J.
29/M/S
Oton, Iloilo
Religon:
CC: Cough

3 days PTC (+) cough, productive phlegm associated with nasal catarrh.
(-) fever (-) anosmia/ageusia (-) sore throat (-) anorexia (-) throat itchiness (-) GI losses
(-) DOB (-) exposure to COVID + patient
No consult done. No meds taken.
Blood-tinged phlegm
Work
History of travel to or residence in an area

Night PTC, (+) back pain, left upper area

(+) persistence of cough and nasal catarrh.
No consult done. No meds taken.
Onset
chronic, trauma last year, dull pain, on and off, (-) persistent, 5/10, during cough and
cold
Duration
Character: stabbing, burning,
Radiation
Aggravate
Relieving
Timing: during cough
Pain scale
History of trauma

On the day of consult, persistence of symptoms thus this consult.

DDX:
- pneumonia
- tb
- flu

Unremarkable PMH
Fully vaccinated (Sinovac)
Pfizer Booster – a week ago

Non-smoker, occasional alcoholic beverage drinker

Staff, Laundry department
Lives with 4 other household members with no symptoms
All have separate rooms, shares a common bathroom

Unremarkable Family History

Vital Signs:
Temp 36.3
BP 110/90
CR 100
RR 20
O2 sat 98%

Weight 80 kg
Height 162 cm

Plans:
For RT PCR swab for SARS CoV-2
CXR PA view

Start:
Azithromycin 500mg 1 tab OD x 5 days
Ambroxol 75mg 1 tab OD x 7 days
Vitamin C + Zinc 1 tab OD
Levocetirizine + Monteleukast 5/10mg 1 tab ODHS x 7 days
Orphenadrine + Paracetamol 1 tab Q8H PRN for back pain