Hi . Here is a 27 yr old male patient with h/o fever since 8 days progressed to thrombocytopenia and myocarditis with ejection fraction 23% with AKI , now with cxr as above.. Dengue n malaria negative and sputum for afb neg, pt is concious and tachypnoeic in resp failure(paO2-55)... Pl discuss the managment protocol .. Thanks.

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the xray shows bilateral non homogeneous infiltrate with ?mottling. with the underlying myocarditis the xray could suggest: 1. pulm edema 2. ards check pao2/fio2 bit since cardia involved u need PCWP to say non cardiogenic ards 3. atypical pneumonia 4. military TB management: 1.start him on Bipap with o2 if he tolerates the need for intubation to be explained. 2. start injection piperacillin tazobactum 4.5g iv q6h azithromycin 500mg iv OD 3.start Inj methyl pred 1mg/kg infusion over 24hrs which will help both ards and myocarditis 4. if patient also has urti symptoms he will need tamiflu 75mg bd 5. if BP is holding start on B blocker like nebicard 2.5mg 1-0-1 if no controindication sent for blood culture, sputum c/s and afb, throat swab for H1N1. d get ecg and echo, cpk and IgM leptospirosis, c3,c4 if he has h/o recurrent urti or any hematuria currently sent work up for small vessel vasculitis

most important sent a peripheral smear and he may need bone marrow for his cytopenia
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Test further to be done are scrub typhus and h1n1 these two condition may be pt into Ards initiate patient with cpap support @ 8 cm.of water start tamiflu.. early start will help till diagnosis is made keep pt in negative balance diuretics and dobutamine doxycycline

Thank you

Thank you