25 yr old male came to casuality with shortness of Breath and pedal edema .

25 year old Male with Shortness of Breath and Pedal edema since 10 days

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. This Elog reflects my patient centered online learning portfolio.

This is the case of a 25 year old man.

.A 26 year old male presented with worsening breathlessness since 3 hours post binge (90ml whiskey ) 


His earliest recall of events dates back to when he was studying in high school ( 9th class ) during the lunch break, he felt severe breathlessness and had to sit back while playing with copious amounts of ?sputum expectoration which he describes it as yellowish in colour and non foul smelling, he describes the incident like he is an old man and needs to sit back to catch up breath 


He continues to feel breathlessness through out his teens and he needs to rest often associated with palpitations on further asking to describe the palpitations it was of pounding nature ( in his words hitting a wall with loud thump ) lasting for 1-2 hours aggravating on lying down 


He often developed respiratory tract infections with history cough with copious amounts of expectorant, sore throat and running nose with is relieving on taking medication ( tab azithromycin). On asking his mother she gave a long history of repetitive infections since childhood once or twice a year and avoiding foods aggravating his cough and cold he was taken to hospital at one year of age for breathlessness


He’s the third born child with term pregnancy  normal vaginal delivery with meconium aspiration and was diagnosed to be dextrocardia on 4th day of delivery as he was sick they were referred to many hospitals and was discharged after relieving his symptoms. 

He was also advised to practice to sit with head low and knees apposed to chest which resulted in vain 


He’s married to his wife and alcohol since two years with occasional binge ( once or twice weekly ) whiskey preferably (90-180ml ) says post binging breathlessness decreases and doesn’t get sputum,he works as an VRO ( village revenue officer ) since after his father was retired and finds it difficult as its not a desk job and halts regularly to catch up breath 


14 days back under the influence of alcohol he had a history of fall from bike 

Sustained head injury with no history of loss of consciousness, ENT bleed and denied going to hospital as he was alright and developed fever on subsequent day subsided on medication

 

History of pedal oedema since 10 days extending upto knee pitting type progressively increasing and attained the present state, he denies history of pedal oedema prior to these 10 days and also denies history of hematuria and frothy urine or decreased urine output and facial puffiness 


3 days back on occasion of raksha bandhan 

Post binge he had 3 episodes of vomiting in the morning was taken to a local doctor revealing potassium 3.2 and creatinine 2.2,TLC -16000 and was given fluids and antiemetic medication 


Since 3 hours he developed breathlessness post binge and was brought to casualty with spo2 41% on RA and 84% on 15L of oxygen.

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)

Usg Abdomen.

RBS

Serum Creatinine

Serum urea

Serum Electrolytes

INVESTIGATIONS :

ECG -

 
Chest x-ray

Hemogram-

CUE-

Blood Sugar Random -


Blood Urea -


LFT -


Serum Creatinine -


Serum Electrolytes -


ABG -


Ultrasound Report -


27/08/2021:
ABG-

Serum electrolytes-
2D Echo:
HRCT :
Fever chart-



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.


SOAP NOTES : SUBJECTIVE:fever spikes absent.


OBJECTIVE

Temperature-98 F

Bp-90/70 mmhg

PR- 120bpm

RR -17cpm

CVS-S1,S2+

RS- BAE+

spo2-96%on 10 lit of oxygen


ASSESSMENT-

Viral Pneumonia

Kartergenour syndrome


PLAN OF CARE- 

1.Inj.Levofloxacin 750mg/iv/BD

2.inj Doxy 100mg/IV/BD

3.inj.Ceftriaxone 1gm/iv/BD

4.inj.Lasix 20mg/Iv/BD

5.inj.Thiamine 1amp in 100ml NS Iv/BD

6.Nebulisation with Budecort 12th hrly

7.i/o charting

8.Bp/PR/RR/spo2 monitoring

9.intermittent CPAP evry 2nd hrly.

28/8/2021

SOAP NOTES : SUBJECTIVE:fever spikes absent.


OBJECTIVE

Temperature-98 F

Bp-110/70 mmhg

PR- 80bpm

RR -17cpm

CVS-S1,S2+

RS- BAE+

spo2-98%on 7 lit of oxygen


ASSESSMENT-

Viral Pneumonia

Kartergenour syndrome


PLAN OF CARE- 

1.Inj.Levofloxacin 750mg/iv/BD

2.inj Doxy 100mg/IV/BD

3.inj.Ceftriaxone 1gm/iv/BD

4.inj.Lasix 20mg/Iv/BD

5.inj.Thiamine 1amp in 100ml NS Iv/BD

6.Nebulisation with Budecort 12th hrly

7.i/o charting

8.Bp/PR/RR/spo2 monitoring

9.intermittent CPAP evry 2nd hrly

29/08/2021

SOAP NOTES : SUBJECTIVE:fever spikes absent.


OBJECTIVE

Temperature-98 F

Bp-100/70 mmhg

PR- 88bpm

RR -18cpm

CVS-S1,S2+

RS- BAE+

spo2-98%on 7 lit of oxygen


ASSESSMENT-

Viral Pneumonia

Kartergenour syndrome


PLAN OF CARE- 

1.Inj.Levofloxacin 750mg/iv/BD

2.inj Doxy 100mg/IV/BD

3.inj.Ceftriaxone 1gm/iv/BD

4.inj.Lasix 20mg/Iv/BD

5.inj.Thiamine 1amp in 100ml NS Iv/BD

6.Nebulisation with Budecort 12th hrly

7.i/o charting

8.Bp/PR/RR/spo2 monitoring

9.intermittent CPAP evry 2nd hrly

31/08/2021

SOAP NOTES : SUBJECTIVE:fever spikes absent.


OBJECTIVE

Temperature-98 F

Bp-120/70 mmhg

PR- 88bpm

RR -18cpm

CVS-S1,S2+

RS- BAE+


spo2-96%on 5 lit of oxygen

spo2-74%without oxyymask 


ASSESSMENT-

Viral Pneumonia

Kartergenour syndrome


PLAN OF CARE- 

1.Tab.Levofloxacin 750mg/iv/BD

2.TabDoxy 100mg/IV/BD

3.inj.Ceftriaxone 1gm/iv/BD

4.inj.Thiamine 1amp in 100ml NS Iv/BD

5.Nebulisation with Budecort 12th hrly

6.i/o charting

7.Bp/PR/RR/spo2 monitoring

8.intermittent CPAP evry 2nd hrly

1/09/2021

SOAP NOTES : SUBJECTIVE:fever spikes absent.


OBJECTIVE

Temperature-98 F

Bp-130/70 mmhg

PR- 98bpm

RR -17cpm

CVS-S1,S2+

RS- BAE+


spo2-97%on 5 lit of oxygen

spo2-75%without oxyymask 


ASSESSMENT-

Viral Pneumonia

Kartergenour syndrome


PLAN OF CARE- 

1.Tab.Levofloxacin 750mg/iv/BD

2.TabDoxy 100mg/IV/BD

3.inj.Ceftriaxone 1gm/iv/BD

4.inj.Thiamine 1amp in 100ml NS Iv/BD

5.Nebulisation with Budecort 12th hrly

6.i/o charting

7.Bp/PR/RR/spo2 monitoring

8.intermittent CPAP evry 2nd hrly

3/09/2021 

WARD PATIENT SUBJECTIVE:SOB subsided. 


OBJECTIVE

Temperature-98 F

Bp-110/70 mmhg

PR- 88bpm

RR -14cpm

CVS-S1,S2+

RS- BAE+ rt IAA crepitus +

P/A- soft, non tender 


ASSESSMENT- 


Viral Pneumonia

Kartergenour syndrome 


PLAN OF CARE-  


1.Tab . MVT PO/OD 


2.tab Thiamine 100mg PO/OD 


3.Nebulisation with Budecort 12th hrly duolin 6th hrly 


4.Bp/PR/RR/Temp charting 4th hrly

4/09/2021 

WARD PATIENT SUBJECTIVE:SOB Subsided


OBJECTIVE

Temperature-98 F

Bp-120/70 mmhg

PR- 90bpm

RR -17cpm

CVS-S1,S2+

RS- BAE+ rt IAA crepitus +

P/A- soft, non tender 


ASSESSMENT- 


Viral Pneumonia

Kartergenour syndrome 


PLAN OF CARE-  


1.Tab . MVT PO/OD 


2.Tab Thiamine 100mg PO/OD 


3.Nebulisation with Budecort 12th hrly duolin 6th hrly 


4.Bp/PR/RR/Temp charting 4th hrly

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