A 26yr old male patient complaints SOB,fever with chills and cough



 December 20,2021

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs. 

Date of admission December 18,2021

CHIEF COMPLAINTS 

A 26 yr old male patient came to the OPD with chief complaints of fever with chills,cough and breathlessness 

HISTORY OF PRESENT ILLNESS  

Patient was apparently asymptomatic 5months back.

4months back he drunk and drove his bike and met with an accident with some injuries and was admitted in the nearest hospital.There while he was receiving his treatment he developed fever with chills,cough with sputum and bipedal edema and then he was admitted into KIMS.He received treatment for about 10days and later his symptoms subsided was discharged 

In between the duration gap between these august and the date of admission he developed the same episodes of symptoms for about 3times for which he consulted a RMP doctor and later the symptoms subsided on taking medication.

3days back patient developed fever with chills,cough with sputum(green phlegm) Shortness of breath(Grade-3)

History of vomiting day before the admission-1 episode bilious colour.

SOB aggravates on lying down position and relieves when turned to one side.

Patient gave a history of consanguineous marriage of his parents and he was diagnosed with dextrocardia on the 4th day of his birth for which he was given treatment and later he was discharged after relieving the symptoms 

HISTORY OF PAST ILLNESS 

No history of diabetes,hypertension,asthma,tuberculosis and epilepsy.

PERSONAL HISTORY 

Patient has no loss of apetite 

Mixed diet

No sleep disturbances 

Bowel and bladder-normal

Patient has history of consuming alcohol daily 90 ml,he now withdrawn the habit 4months back

No history of smoking.

FAMILY HISTORY 

No similar complaints in the family 

GENERAL EXAMINATION 

Patient is conscious,coherent and cooperative 

No pallor,icterus,clubbing,cyanosis,regional lymphadenopathy 

VITALS AT ADMISSION 

Temperature-99.3F

Respiratory rate-38 cycles/min

Pulse rate-104beats/min

Blood pressure-90/60mmHg








SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM


Inspection - chest wall is bilaterally symmetrical

- No precordial bulge 

- No visible pulsations, engorged veins, scars, sinuses, carotid artery was prominent 

Palpation - JVP is not seen 

 Auscultation -  S1 and S2 heard, apex beat is heard in the 5th rib interspace medial to the nipple

RESPIRATORY SYSTEM 

No dysponea

No wheezing

Trachea is centrally positioned

Vesicular breath sounds 

Adventitious sounds-B/L crepts IAA/IMA

PER ABDOMEN 

Shape of abdomen-scaphoid 

No tenderness

No palpable mass

Hernial orifice-normal

No free fluid present

No bruits

Liver and spleen not palpable 

Bowel sounds-present 

CENTRAL NERVOUS SYSTEM 

- Patient is conscious

- Speech is present

- Reflexes are normal

PROVISIONAL DIAGNOSIS 

Kartagener syndrome associated with viral pneumonia 

INVESTIGATIONS 


CHEST X-ray 


Hemoglobin-16.6%

Total leukocyte count-14,800/ml

Platelet count-2,91,000/ml

LIVER FUNCTION TEST 

Total bilirubin-2.62mg/dl

Direct bilirubin-0.62mg/dl

AST-25IU/L

ALT-22IU/L

Total proteins-7.3gm/dl

Albumin-2.2gm/dl

RENAL FUNCTION TEST 

Urea-37mg/dl

Creatinine-1.1mg/dl

Serum electrolytes

Calcium-10.2mg/dl

Sodium-140mEq/L

Pottasium-5.5mEq/L

Chloride-92mEq/L

TREATMENT 

Neb-budecort-12th hourly

       -ipravent-8th hourly 

Inj Lasix 20mg/IV/BD

Inj PANTOP 40mg/IV/OD

Inj NORAD 2amp in 48ml normal saline

Inj Augmentin 1.2gm/IV/BD

Tab Azithromycin 500mg/PO/OD

Tab Paracetamol 650mg





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