Case Presentation: Respiratory Distress in a Young Male

2. CASE PRESENTATION BY DR AYESHA TAHIR PGT MU1, Benazir Bhutto Hospital

3. Demographic Profile Mr. W 28 year-old male Unmarried Unemployed Resident of Rawalpindi Date of Admission: 15-jan-2018 Mode of Admission: Medical Emergency

4. Presenting complaints • Fever • Shortness of breath 7 days • Cough

5. History of Presenting Complaints • Fever Sudden, continuous, up to 104 with rigors and chills • Shortness of breath On mild exertion • Cough Productive, copious sputum, greenish, foul smelling and blood streaked No associated chest pain

6. Past Medical and Surgical history • Normotensive, normoglycemic and non-smoker • Episodes of fever, cough and difficulty in breathingsince childhood • Multiple admissions in hospital • No history of TB or TB contact No significant surgical history.

7. Personal History • Uneventful birth, normal milestones • History of missing school days and taking long leaves during academic tenure • Good learner, completed his graduation • Left his job due to illness

8. Family History • Three siblings • Two siblings with similar complaints • One sibling healthy • Both parents are alive and healthy • Consanguineous marriage • Mother is on anti-depressants

9. Drug history • Oral and inhaled steroids • Inhaled beta-2 agonist • N-acetyl cysteine sachet • Chest physiotherapy • Advised PEP device (Positive Expiratory Pressure) Gets annual flu vaccine Pneumococcal vaccine advised every five years

10. Systemic Inquiry

11. GENERAL PHYSICAL EXAMINATION A young male of normal height, lean, dyspnoeic, sitting on a wheel chair with obvious discomfort, well oriented in time, place and person with vitals as:

12. GENERAL PHYSICAL EXAMINATION

19. Differential Diagnosis

20. MANAGEMENT • Admitted in ward • Supplemental oxygen • Chest Physiotherapy • Nebulization with inj Colomycin and hypertonic saline • N-acetyl cysteine sachet • Inj Piperacillin/Tazobactam4.5g IV QID • IV Steroids • Inhaled beta-2 agonist

21. INVESTIGATIONS

22. BLOOD CP

23. BLOOD BIOCHEMISTRY

24. SERUM ELECTROLYTES

25. Urine RE

26. ARTERIAL BLOOD GASES

27. SPUTUM EXAMINATION

29. ECG

30. CXR (PA VIEW)

31. HRCT CHEST

32. CT PNS (coronal view)

33. CT PNS (axial view)

34. 2D Echocardiography • Normal sized cardiac chambers with LVEF 60% • Valves appear normal • No regional wall motion abnormality • PAP 30mmHg

35. Spirometery

36. GENOTYPING DELTA F508 MUTATION ON CFTR GENE Negative

37. Immuno assay

38. SERUM PROTEIN ELECTROPHORESIS

39. CTDscreening

40. A REVIEW OF MEDICAL HISTORY OF SIBLINGS

41. SIBLING ONE • Mr. S, 30-year old male, Unmarried and Unemployed

42. Fever, productive cough and SOB ever since birth • Multiple admissions in hospital • Severe headache and nasal obstruction • A preterm delivery • A slow learner, studied till 9th grade

43. Examination • Clubbing • Apex beat palpable at right 5th intercostal space along midclavicular line • Bilateral inspiratory coarse crepitations • Right sided DNS • Left inferior turbinate hypertrophy • Bilateral nasal polyps

44. INVESTIGATIONS

45. ECG

46. CXR (PA view)

47. CT CHEST

49. CT PNS (coronal view)

50. CT PNS (axial view)