College

Case Study:

**Patient Information:**
- Name: J.C.
- Age: 44 years old
- Gender: Male
- Admission: Emergency Room (ER)
- Primary Concern: Shortness of breath

**Medical History:**
- Condition started 7 days prior to admission.
- Initial symptoms: High-grade fever, malaise, non-productive cough.
- Sought advice from a neighbor and took anti-parasitic drugs with no improvement.
- Symptoms progressed to include persistent shortness of breath and loss of taste.
- Consultation with a doctor friend revealed oxygen saturation at room air of 87%.
- Difficulty in breathing noted, prompting immediate ER admission.

**Past Medical History:**
- Unremarkable

**Family Medical History:**
- Unremarkable

**Personal Social History:**
- Occupation: Market vendor
- Daily workplace exposure while selling goods

**Review of Systems:**
- Unremarkable

**Physical Examination:**
- General Survey: Patient is conscious, coherent, and oriented to time, place, and person.
- Vital Signs:
- Blood Pressure: 120/70 mmHg
- Heart Rate: 110 bpm
- Temperature: 38.8°C
- Oxygen Saturation (Room Air): 85%
- Skin: Unremarkable
- Head: Unremarkable
- Eyes: Pink palpebral conjunctivae, anicteric sclerae
- Ears: Symmetrical and non-tender auricles; auditory canals patent, pink mucosa, intact tympanic membrane
- Nose: Symmetrical, (+) alar flaring, pink mucosa, midline and intact septum
- Mouth and Oral Cavity: Unremarkable
- Neck: Supple, symmetrical, no neck vein engorgement, no mass, no palpable lymph nodes
- Lungs/Chest: Symmetrical chest expansion, no retractions, no deformities, equal tactile and vocal fremitus, (+) crackles from mid to base on auscultation
- Heart: Adynamic precordium, no heaves or thrusts, no palpable thrills, apex beat at the 5th intercostal space left midclavicular line, tachycardic, regular rhythm
- Abdomen: Unremarkable
- Extremities: Unremarkable

**Laboratory Results:**
- COVID-19 Antigen Test: Positive
- Nasopharyngeal Swab (NPS) and Oropharyngeal Swab (OPS) for COVID-19 PCR: Positive
- SARS-CoV-2 IgG and IgM: Negative

**Summary:**
The patient presented with worsening respiratory symptoms consistent with COVID-19, confirmed by laboratory testing.

Answer :

J.C., a 44 year-old male came to ER with fever, non-productive cough, dyspnea, and loss of taste. Diagnostic tests show COVID-19 positive. Physical exam showed low oxygen saturation.

The patient, J.C. is a 44-year-old male who complained of shortness of breath upon admission to the ER. He experienced a high fever, malaise, and cough seven days before admission. The cough was non-productive and unresponsive to the anti-parasitic drugs. His doctor friend conducted a home visit and admitted J.C. to the ER after noting low oxygen saturation and respiratory distress.

The physical exam revealed a temperature of 38.8°C, pink palpebral conjunctivae, anicteric sclerae, and low oxygen saturation of 85% on room air. Diagnostic tests showed COVID-19 positive via PCR. The COVID-19 Ag test of the nasopharyngeal swab was positive, while the SARS COV 2lgG−lgM test was negative. These findings indicate an acute COVID-19 infection. The patient's medical history and family history were unremarkable. The patient is a market vendor and goes to work every day.

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