A 67 year old male came with shortness of breath and fever

Hi, I am sravya , 5rd Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

I have 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. 

CHIEF COMPLAINTS
Shortness of breath since 1 week and fever since 4 days.
 
HISTORY OF PRESENTING ILLNESS
 The patient was apparently asymptomatic 1 week back . 
 Then he developed shortness of breath which was gradual in onset and progressive in nature.
He complains of fever since 4 days  which was high grade and with evening spike of temperature associated with chills and rigor. It was relieved on medication.
He also complains of 2-3 episodes of vomiting which was  non projectile and non bilious, watery .
He complains of loose stools ,2-3 episodes per day , watery , not foul smelling ,not blood stained.
Complains of decreased urine output since 6 months.
Also complains of pain abdomen in the left lumbar region since 1 week  which was on and off type , dragging type and non radiating .
 
PAST HISTORY

Has HTN since 10 years
No H/o DM, CAD, Asthma,TB.

FAMILY HISTORY
Insignificant

PERSONAL HISTORY
Married 
Barber 
Mixed diet
Decreased appetite since 1 week
Adequate sleep
Irregular bowels
Decreased urine output since 6 months
Addictions - tobacco but stopped 
Alcohol but stopped
No known addictions 

GENERAL EXAMINATION 
       Conscious and coherent and cooperative 
       Moderately built
       Moderately nourished 
       No pallor
       No icterus
       No cyanosis, clubbing of fingers , lymphadenopathy, pedal oedema  

VITALS 
 Temperature - 98.9F
  Pulse rate - 117beats /minute
  Respiratory rate - 28/min
  BP -120/70 mm of Hg
 
SYSTEMIC EXAMINATION

 CVS 
 No thrills 
 S1 S2 + 
 No cardiac murmurs

RESPIRATORY SYSTEM
Centrally located trachea 
Vesicular breath sounds 
No dyspnea
No wheezing 

ABDOMEN
Shape - obese
Tenderness in left lumbar region 
No palpable mass
 
CNS 
Conscious and coherent
Normal speech
 
INVESTIGATION
 ULTRASOUND EXAMINATION

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