25 YEAR OLD MALE WITH VIRAL PNEUMONIA AND KARTAGENER SYNDROME

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Name: Sreshta J

Roll no: 48

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

I have further referred the case from my Senior’s elog. Thank you for the consent sir.

https://katanaveenkumar.blogspot.com/2021/08/25-yr-old-male-with-shortness-of-breath.html

Following is the view of my case :

CASE PRESENTATION

A 25-year-old male has presented to the OPD on 25 August 2021 with the chief complaints of

• shortness of breath since 10 days
• pedal oedema since 10 days

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 10 days ago when he developed shortness of breath (SOB from hereafter) after consuming 90ml of whisky. He first consulted an RMP, who gave him fluids and was later referred to our tertiary care hospital. 

He was diagnosed with dextrocardia on 4th day of delivery.

SOB: 

• He has been suffering from SOB since his teens. As the patient recalls his first episode happened when he was 14 years old while he was playing in school. Copious amounts of expectoration were seen. It was yellowish in colour and non-foul smelling.
• Has a history of respiratory tract infections which occur almost twice a year. It is aggravated by exposure to cold temperature and relieved by taking medication.

Pedal oedema:

• Was in a bike accident 14 days ago and sustained a head injury.
• Refused to go to the hospital to get checked 
• Developed oedema 3 days later which extended up to the knee.

PAST HISTORY :

• not a known case of hypertension, diabetes, asthma, epilepsy or tuberculosis.

PERSONAL HISTORY :

• married
• lost appetite
• takes mixed diet
• bowel movements are regular
• micturition is normal
• no known allergies
• addictions: has been consuming alcohol twice weekly for 5 years.

FAMILY HISTORY:

No similar complaints in the family.

TREATMENT HISTORY:

He was given fluids by RMP before admitting to our hospital.

GENERAL EXAMINATION:

Done after obtaining consent, in a well-lit room, in the presence of an attendant, with adequate exposure. The patient is conscious, coherent, cooperative, well-nourished, well -oriented to time, place, person.

• No pallor, icterus, Cyanosis, Koilonychia, Generalised Lymphadenopathy
• Pedal oedema and clubbing of the fingernails was seen.

Fig: Clubbing of fingernails

VITALS at the time of admission:

• Temperature - 97.6 degrees Fahrenheit
• Pulse rate- 120 bpm
• BP- 150/70 mm Hg
• Respiratory rate- 40/min
• SpO2- 41% at room temperature

SYSTEMIC EXAMINATION:

1. CVS: S1 & S2 heard

2. Respiratory system: 

• Dyspnoea - present

3. Abdomen: Soft and non-tender

4. CNS: No focal deficit

INVESTIGATIONS:

CBP

• Hb- 17.8gm/dl
• total count- 12600 cells per cumm
• neutrophils- 82%
• leucocytes- 12%
• PCV- 55.6vol%
• RBC- 6.3million/cumm
• Platelets- 1.3lakhs/cumm
• Impression: Normocytic normochromic blood picture with neutrophilic leucocytosis and mild thrombocytopenia.

ECG

ABG

LFT

Serology- negative for Covid-19

Chest X-ray (PA View)- Dextrocardia 

USG Abdomen

Serum Electrolytes

CUE - Normal

RBS- 101mg/dl

Serum Creatinine- 1mg/dl

Serum urea- 48mg/dl

PROVISIONAL DIAGNOSIS:

?Kartagener syndrome- Dextrocardia, situs inversus & bronchiectasis

?Viral pneumonia 

TREATMENT PLAN  (given on 25 August 2021):

1. Head end elevation 
2. O2 inhalation to maintain SpO2 at 92%
3. Nebulizer with Duolin 8th hourly
4. BP, PR, SpO2, temperature monitoring 4th hourly
5.  Inj Lasix 40 mg BD
6.  Inj Thiamine 1 ampoule in 100ml NS IV BD
7.  Inj Levofloxacin 750mg IV OD
8. Inj Doxycycline 100mg IV BD
9. Inj Ceftriaxone 1gm IV BD

SOAP NOTES:

26 August 2021

Subjective: Shortness of breath

Objective: 

• Temperature - afebrile
• Pulse rate- 133bpm
• Respiratory rate- 45/min
• SpO2- 95% on 15 lit of O2
• CVS: S1 & S2 heard
• Respiratory system: Dyspnoea - present
• Abdomen: Soft and non-tender
• CNS: No focal deficit

2D ECHO Report:

• no RWMA
• mild PAH
• good LV systolic function
• IVC dilated

Assessment:

• Kartagener syndrome
• Viral pneumonia

Plan of care:

1. Inj Levofloxacin 750mg IV OD
2. Inj Doxycycline 100mg IV BD
3. Inj Ceftriaxone 1gm IV BD
4. Inj Lasix 20mg IV BD only if systolic blood pressure > 110mmHg
5. Nebulizer with Duolin 8th hourly
6. Inj Thiamine 1 ampoule in 100ml NS IV BD
7. BP, PR, SpO2, temperature monitoring 2nd hourly
8. Intermittent CPAP every 2nd hourly
9. Temperature charting
   
   
   

28 August 2021

Subjective: Fever spikes absent, SOB decreased

Objective: 

• Temperature-98 F

• Bp-110/70 mmHg

• PR- 80bpm
• RR -17cpm
• CVS-S1, S2 heard
• RS- BAE+
• spo2-98%on 7 lit of oxygen

Assessment:

• Viral Pneumonia
• Kartergener syndrome

Plan of care:

1. Inj.Levofloxacin 750mg/iv/BD

2. Inj Doxycycline 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 hourly

7. Temperature charting

8. Bp/PR/RR/spo2 monitoring

9. Intermittent CPAP every 2nd hourly

29 August 2021

Subjective: Fever spikes absent, SOB decreased

Objective: 

• Temperature-98 F
• Bp-100/70 mmHg
• PR- 88bpm
• RR -18cpm
• CVS-S1, S2 heard
• RS- BAE+
• spo2-98%on 7 lit of oxygen

Assessment:

• Viral Pneumonia
• Kartergener syndrome

Plan of care:

1. Inj.Levofloxacin 750mg/iv/BD

2. Inj Doxycycline 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 hourly

7. temperature charting

8. Bp/PR/RR/spo2 monitoring

9. Intermittent CPAP every 2nd hourly

31 August 2021

Subjective: Fever spikes absent, SOB decreased

Objective: 

• Temperature-98 F
• Bp-120/70 mmHg
• PR- 88bpm
• RR -18cpm
• CVS-S1, S2heard
• RS- BAE+
• spo2-96%on 5 lit of oxygen
• spo2-74%without oxy mask 

Assessment:

• Viral Pneumonia
• Kartergener syndrome
• HRCT report
  
  
  

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 hourly
7. Bp/PR/RR/spo2 monitoring
8. Intermittent CPAP every 2nd hourly
6. temperature charting

02 September 2021

Subjective: No fresh complaints

Objective: 

• Temperature- afebrile
• Bp-110/70 mmHg
• PR- 84bpm
• RR -14cpm
• CVS-S1, S2heard
• RS- Crepitus heard
• spo2-84% at RT

Assessment:

• Viral Pneumonia
• Kartergener syndrome

Plan of care: 

1. Inj.Thiamine 1amp in 100ml NS Iv/BD
2. Nebulisation with Budecort 12th hourly
3. O2  inhalation to maintain SpO2 at 94%
4. Bp/PR/RR/spo2 monitoring

03 September 2021

The patient is being discharged.

ACKNOWLEDGEMENT:

I'd like to extend my sincere gratitude to Dr Rakesh Biswas sir (HOD, General Medicine) for providing me with this opportunity, as well as Dr Naveen sir (Intern).