A 25 year old Male with Shortness of Breath and Pedal edema since 10 days
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This Elog was created under the guidance of Dr Naveen (Intern).
This is the case of a 25 year old man.
CHIEF COMPLAINT :
Shortness of Breath
Pedal edema since 10 days
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 10 days back. & then he presented with worsening breathlessness 3 hrs post binge (90) whisky.
His earlier events 9th class - Had an episode of SOB and had to sit back while playing with copious amount of sputum with expectoration (yellowish color, non foul smelling).
He continuies to feel breathlessness in his teen's and needs rest often ass with palpitations (pounding nature 1- 2 hrs).
Often developed respiratory tract infection with history of cough & copious amount of expectoration, sore throat running nose. Relieved on taking Medication.
He also have repetitive history of infection twice a year & avoiding foods, aggravating his cough & cold be was taken to hospital for breathlessness at a age of 1 year.
He was diagnosed of baving dextrocardia on the 4thday of delivery and referred to hospital & advised to practise to sit with head low and knees opposed to chest, which resulted in vain.
H/O - since 2 years once or twice whisky (90-180 ml) → occasionally binge and says post binging breathlessness decreases and doesn't get sputum.
14 days back - history of fall from bike under the influence of alcohol & sustained head injury with no loss of consciousness and bleed.He developed fever on subsequent day, relieved on medication.
History of pedal edema since 10 days extending up to knee Pitting type, progressively increasing.
3 days back he has post binge with 3 episodes of vomiting taken to local hospital.
HISTORY OF PAST ILLNESS :
No history of DM, Hypertension, Epilepsy and Tuberculosis.
No past surgical history.
GENERAL EXAMINATION
Patient is conscious and cooperative
No pallor, icterus, cyanosis
With clubbing of fingers and pedal edema.
No generalised lymphadenopathy.
VITALS AT ADMISSION
Temperature - 97.6 degrees fahrenheit
Pulse- 120 bpm
BP- 100/70 mmHg
SPO2 at Room air 41.1 % at 84 % on 15 litters of O2.
INVESTIGATIONS ORDERED :
Hemogram
HIV
ECG
LFT
Serology
Chest X ray (PA View)
Ush Abdomen.
RBS
Serum Creatinine
Serum urea
Serum Electrolytes
INVESTIGATIONS :
ECG -
Blood Sugar Random -
PROBABLE DIAGNOSIS :
Kartagener syndrome ?
Viral pneumonia ?
TREATMENT :
25.8.2021
1. Inj lasix 40 mg
2. Inj Thiamine.
3. Inj Levofloxacin
4. Inj Doxycycline
5. Inj Ceftriaxone
26.8.2021
1. Inj. Levofoxacin
2. Inj Doxycycline
3. Inj Ceftriaxone
4. Inj lasix 40 mg
5. Inj thiamine.
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