55 yrs old male with CKD and SOB

 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 blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

CASE PRESENTATION

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 diagnosis and treatment plan .

55 yrs male patients came to opd with 

Chief complaints :

-back pain since 3 months                                             

-reduced sleep since 3 months 

-sob since 1 month 

- b/l pedal edema since 1 month 

History of presenting illness :

Patient was apparently asymptomatic 3 months back then he developed back pain which is insidious in onset , which started with lower back pain then after 1 week radiated upwards, aggravated on prolong sitting and during physical activity , relieved on rest and supine position. He had reduced sleep due to back pain 

Then later he developed sob which is insidious in onset , gradually progressive from grade-1 to grade -3 , aggravating on physical activity , no reliving factors 

Later he developed b/l pedal edema is developed 1 month ago which is pitting type extended Upto knee 

No h/o cough , fever , vomitings , nausea , palpitations , burning micturition

Past history :

He is a known case of hypertension and diabetes 

No h/o asthma , epilepsy , tuberculosis 

Family history : 

No significant family history 

Personal history :

Diet - mixed 

Regular bowel and bladder movements 

Reduced sleep 

Addictions - occasionally drinks alcohol 

Normal appetite

No allergies 

Treatment h/o -

Clonidine - 0.1 mg 

Undergoing heamodialysis

General examination :

Patient is conscious , coherent , cooperative 

Moderately built and moderately nourished 

Pallor present 

No icterus , no cyanosis , no clubbing , no lymphadenopathy 

Vitals 

Bp: 110/70 mmhg 

Temperature - afebrile 

Rr- 16 cpm 

Hr - 80 bpm 

Systemic examination -

Respiratory examination:

Inspection - 

Upper respiratory tract :

Normal 

Lower respiratory tract : 

Chest appears to Be symmetrical 

B/l chest movements are equal 

Chest shape appears to Be elliptical 

Trachea appears to Be normal

Apical impulse is seen 

 No h/o drooping of shoulder , no spine deformities ,

 no visible scars , sinuses , dilated veins , nodules , swelling 

No hallowing is seen 

Palpation - 

Confirmed inspiratory findings 

Trachea - midline 

B/l chest movements are equal 

No local rise of temperature 

No tenderness , no crowding of ribs , 

Vocal fermitus - normal 

Percussion - 

Resonant 

Auscultation - 

B/l vesicular breath sounds 

Vocal resonance - normal 

Per abdomen - 

Non tender , soft 

Cardiovascular system - 

S1 , s2 heard ; no murmurs 

Central nervous system - 

No focal deficits 

Provisional diagnosis - 

CKD with sob