80M with SOB, body pains and lower backache

Case of 80yr old male with shortness of breath, body pains and lower backache

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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 

A 80yr old male came to the opd with shortness of breath since 4 months, body pain since 4 months and lower backache (right side) since 6 months

HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic 6 months ago then he developed lower backache on right side since 6 months 

Insidious in onset and gradually progressive in nature, dragging type of pain, intermittent in nature, aggravated on walking and relieved on rest. Shortness of breath since 6 months which is present on ordinary and less than ordinary activity , grade (2-3) relieved on rest.

No C/O chest pain, orthopnea, PMD,decreased urine output, pedal edema or facial puffiness. Generalised body pains 4 months.

PAST HISTORY 

Not a known case of hypertension, DM, CVA,CAD,TB, asthma.

20 yrs back he had cataract surgery for his right eye and 15 yrs back he had the same for his left eye.

3 yrs back he met with an accident and had tibial fracture and was taken to local hospital for treatment where he was also diagnosed with CKD.

1yr back when he went for the removal of the rods in his leg he had an infection with swelling of his foot.

6 days back he had chest pain radiating towards right for which he went to RMP and was given a pill which gave him relief. 

FAMILY HISTORY 

No significant family history

PERSONAL HISTORY

Alcohol and smoking bedi since 28yrs 

GENERAL EXAMINATION

Pallor positive 

No signs of icterus, cyanosis, clubbing, lymphadenopathy and pedal edema. 

VITALS

PR: 89bpm

BP: 130/70mm hg

RR: 22 bpm

TEMPERATURE: 98.6F

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM:

S1 S2 heard

no murmurs

RESPIRATORY SYSTEM: 

No added sounds

ABDOMEN EXAMINATION:

Shape: scaphoid

No tenderness, palpable or free fluid

Liver and spleen not palpable

INVESTIGATIONS