A 26yr old male patient complaints SOB,fever with chills and cough
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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Patient has history of consuming alcohol daily 90 ml,he now withdrawn the habit 4months back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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