60 yr old male with CKD

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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Chief complaints:

B/L pedal edema since 2 months

Decreased urine output since 2 months

Breathlessness since 10 days 

HOPI : Patient was apparently asyptomatic 2 months back then he developed b/l pedal edema pitting type gradually progressive extended upto knee aggravated on walking and relieved after dialysis ,

then later he developed decrease in urine output 10-15ml and increase in frequency and has h/o nocturia 

,He then developed Sob 10 days back which was insidious in onset,gradually progressive started with grade 1 and progressed to grade 3 aggravated by walking and relieved on taking prolonged rest 

No H/o Orthopnea ,Chest pain,Pnd 

No H/0 palpitations,sweating

No H/o fever,cough,vomitings

No H/o headche,sleep disturbances

No H/o Hematuria 

Past history : 

K/c/o Diabetes since 6 yrs(tab.glimi)

K/c/o Htn since 3 yrs (tab amlokind)

No h/o Tb epilepsy asthma 

H/o fistulectomy 5 yrs back

PERSONAL: 

Mixed diet 

Normal Appetite

Adequate sleep

Regular bowel  movements.

Decreased urine output 

No allergies

Occasional alcoholic .

No smoking .

FAMILY : No relevant family history

Treatment history: 

Had underwent 4 episodes of dialysis since last 10 days 

General examination: 

GENERAL EXAMINATION

Patient is coherent,conscious and cooperative .

Patient is well nourished.

NO signs of pallor,icterus,cyanosis, clubbing,lymphadenopathy,pedal edema

VITALS:

Temperature :97°F 

Blood pressure: 150 /90 mm Hg

Pulse rate: 78 bpm

Respiratory Rate: 16cpm

GRBS -136mg/dL

Systemic examination:

Respiratory examination:

Inspection- 

Shape of chest- elliptical 

Trachea-central

Chest movements Appears to be bilaterally equal 

No drooping of shoulders

No scars,sinuses,engorged veins 

No crowding of ribs

Palpation-

All inspectors findings confirmed

No rise of temp, tenderness

Trachea midline 

Apical impulse felt 

B/l chest movements equal

No swellings masses are felt 

Vocal fremitus normal 

CVS: S1 S2 heard no murmurs 

CNS: no focal neurological deficits

P/A: non tender , no organomegally

Investigations: 

Ecg: 

Diagnosis: This is a case involving Renal system probably a case of chronic kidney disease