A 64 years old male patient barber by occupation came to casuality with chief complaints of  shortness of breath and pain in abdomen 


History of presenting illness::

Patient was apparently asymptomatic 1 month back and then he developed shortness of breath incidious onset and gradually progressive 

No c/o chest pain,Palpations

C/o fever for 3-4days ,high grade, evening rise of temperature associated with chills and rigor

Since one month patient complaints of breathlessness (grade 3) insidious in onset gradually progressive aggrevated on walking and no seasonal variation. 


Past History::

Decreased urine output since 6 months 

c/o pain abdomen on left lumbar region since 1 week 

patient is a known case of HTN since 10 years for which he is on medication (olmosetron tab)

Not a known case of DM,TB,ASTHMA 

Personal history:

Apettite-decreased

Diet- mixed

Bladder- decreased

Bowel -abnormal

##Addictions- 

Tobacco chewing-stopped 3 yrs back

Alchol-stopped 1yr ago

Family history: 

No significant


Treatment 

Renal stenting has done


General examination::

Patient is conscious,cohorent , cooperative well known with time, place, person 

He is well built and moderately nourish

No pallor 

No Lymphadenopathy

No pedal oedema 

No icterus cyanosis, clubbing.


VITALS :

Temp : 98.9

Pulse rate-117

Blood pressure :120/70mmhg

Respiratory rate :20 cpm

Spo2 : 90%


SYSTEMIC EXAMINATION:


Respiratory system:

Inspection: chest shape normal, 

Breath sounds -vesicular

Dyspnea: present 

Palpation: trachea -central


MANAGEMENT :


INVESTIGATIONS : 

 

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