35 yr old male with Decreased appetite, Vomitings, Pedal edema and Shortness of breath

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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

A 35 year old male came to OPD with a chief complaints of

Decreased appetite since 15 days

Vomiting since 15 days

Bilateral pedal edema since 15days

Shortness of breath since 5days 

HOPI:

Patient was apparently asymptomatic 1 and half year ago then he had symptoms of decreased appetite went to hospital then they diagnosed as kidney disease and he used medication for 1 month and stopped later after six months he developed shortness of breath and bilateral pedal edema then he opted for dialysis then after 1year came with symptoms of decreased appetite with vomiting from past 15days 2 episode per day which is insidious in onset non bilious ,non projectile contain food particles

He had H/O bilateral pedal edema which is pitting type from past 15days

H/o shortness of breath progressed to grade 2

PAST HISTORY:

K/C/O HTN since 1YR on TAB.CLINIDIPINE

H/O kidney disease i.e CKD since 2yr; on dialysis since then.

PERSONAL HISTORY: 

Diet - mixed

Appetite decreased since 1month

Bowel and bladder -regular

Sleep -regular

Addiction - occasionally alcoholic stopped 1year back

FAMILY HISTORY:

Not significant

TREATMENT HISTORY:

On antihypertensive since 1 year

GENERAL EXAMINATION:

Patient is conscious, coherent, Cooperative

No H/o pallor,icterus, cyanosis, lymphadenopathy 

H/o bilateral pedal edema

Vitals:

Temperature -afebrile

BP -170/100 mm Hg

PR- 97bpm

RR -20cpm

GRBS - 115

Systemic examination:

CVS:

Jvp not raised 

Inspection:

Shape of chest - elliptical

No visible pulsations

No engorged veins 

Apical impulse not visible

Palpation:

Apex beat present over the left 5th intercostal space medial to midclavicular line

No parasternal heave

No precordial thrill

No dilated veins

Auscultation:

S1 S2 heard ,No murmurs 

Respiratory system:

Upper respiratory tarct - normal

Lower respiratory tract:

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- central

Palpation:

Trachea is central

Normal chest movements

Vocal fremitus is normal in all areas ( in sitting position)

Percussion: in sitting postion

                                                 Rt.            Lt

Supraclavicular. N(resonant).            N

Infraclavicular. N.                                 N

Mammary region. N.                             N

Inframammary region. N                   N

Axillary region. N.                               N

Infra axillary region. N.                       N

Supra scapular region.N                          N

Interscapular region. N.                         N.  

Infrascapular region. N.                            N

Auscultation:

Normal vesicular breath sounds

No added sounds

Vocal resonance is normal in all areas(in sitting position)

Per Abdomen:

Inspection:

Shape - flat

Flanks - free

Umbilicus - inverted

All quadrants moves equally with respiration 

No engorged veins, visible pulsations

Hernial orifice are free

Palpation:

No local rise of temperature

Abdomen is soft and non tender

No palpable spleen and liver

No other palpable masses

Percussion:

Resonant.

Auscultation:

Normal bowel sounds heard

CNS :

Higher motor functions - intact

Cranial nerves - intact

Motor system:

             Rt- UL. LL.                  Lt- UL. LL

Bulk - normal N.                          N. N 

Tone - N. N.                                   N. N

Power - 5/5. 5/5.                        5/5. 5/5

Reflexes:         

                             UL.                             LL

Biceps. 2+.                                            2+

Triceps. 2+.                                          2+

Supinator. 2+.                                     2+

Knee 2+.                                               2+

Ankle. 2+.                                            2+

Sensory system: intact

Co ordination is present 

Gait is normal

No Cerebellar signs 

No signs of meningeal irritation 

Provisional diagnosis:

CKD ON MHD

Investigations: