70 year male with SOB and abdominal distension

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

A pavan kumar 

1701006011 

Date 16 08 2022 

A patient of age 70 years came to the casualty with chief complaints of 

1) shortness of breathe from 2hours 

2) epigastric pain since afternoon

HOPI 

This is a case of 70 year old male with history of fever since 1 day and pain abdomen since afternoon and shortness of breath since 2 hours 

No h/o of nausea vomiting constipation loose stools 

Patient passed stools and flatus today 

N/K/c/o DM tb asthma epilepsy cad no past surgical

O/E 

Patient is conscious and coperative 

Cold peripheries

Pulse feeble 

Bp 140/90 mm hg 

Secured iv canula and bolus of 200ml NS is given 

Spo2 95%

Cvs  s1 s2 heard 

 Rs BAE present 

P/A 

Abdominal distension in epigastric region 

P/R 

Rectum loaded with faeces 

Provisional diagnosis 

Acute abdominal distension under evaluation 

Lab investigations 

  Treatment

Injection Tramadol 50mcg 

Injection pantop 40mg 

IVF 500ml