45M SOB, KNEE PAIN, FATIGUE AND SWELLING OF LEGS

 2/11/2026

THIS PATIENT DATA WAS GATHERED BY ROLL NO 31, BATCH 2023 AS PART OF THEIR COMPETENCE BASED LEARNING EVALUATION PORTFOLIO PREPARATION

THIS IS THE CASE OF 45M WITH SOB, KNEE PAIN, FATIGUE AND SWELLING OF LEGS

*Demographics*

- Age / Sex: 45 years / Male

- Occupation: Not mentioned

*Chief Complaints*

- Breathlessness on exertion (SOB)

- Knee pain

- Fatigue

- Swelling of legs

*History of Present Illness*

- Patient was apparently normal then developed breathlessness initially on exertion which gradually progressed, also associated SOB.

- Patient also complaints of b/l lower limb swelling (pitting) associated with fluid retention.

- Patient gives history of loss of appetite.

- Also developed b/l knee pain since 1 month which was progressive in nature.

- No H/O burning micturition, fever, hematuria.

*Past History*

- Known case of HTN x 4 yrs ago (Amlodipine x 10 mg)

- History of dialysis since 2 yrs (twice weekly)

- N/K/C/O DM, Asthma, Epilepsy, CAD

*Family History*

- Not significant

*Personal History*

- Diet - Mixed

- Appetite - Decreased

- Sleep - Disturbed

- Bowel & Bladder - Irregular

- Addictions - No addictions

*General Examination*

- Patient is conscious, coherent, oriented to Time / Place / Person

*PICCLE*

- P - Positive (+)

- I - Negative (-)

- C - Negative (-)

- C - Negative (-)

- L - Negative (-)

- E - Positive (+)

*Vitals*

- Temp - 98 °F

- BP - 110 / 90 mmHg

- RR - 17 / min

- PR - 90 / min, Regular

- SpO2 - 97% on room air

*Systemic Examination*

- CVS - S1, S2 (+), No murmurs

- CNS - NFND

- RS - Reduced air entry, dull note

- P/A - Soft, NT

*Provisional Diagnosis*

- Chronic Kidney disease (CKD)

*Department of Pathology - CBC Report*

*Patient Details*

- Age / Sex: 47 years / Male

- Dept / Unit: Emergency Medicine

- Date: 26-Oct-26

*Complete Blood Count*

Investigation | Result | Units | Biological Reference Intervals

Haemoglobin | 7.9 | g/dL | M: 13.5-17.5, F: 12-15

TRBC Count | 2.4 | millions/cumm | M: 4.5-5.5, F: 3.5-5.0

Total WBC Count | 2,600 | cells/cumm | 4000 - 11000

Neutrophils | 84 | % | 40 - 80

Lymphocytes | 12 | % | 20 - 40

Eosinophils | 01 | % | 1 - 6

Monocytes | 03 | % | 2 - 10

Basophils | 00 | % | 0 - 2

PCV | 22.8 | % | M: 40-50, F: 36-44

MCV | 91.8 | fL | 80 - 98

MCH | 31.7 | pg | 27 - 33

MCHC | 34.5 | gm/dl | 32 - 36

Platelet Count | 1.5 | Lakhs/Cumm | 1.5 - 4.5 lakh/Cumm

*Remarks*

- Neutrophilia

- Reactive lymphocytes seen

Here is a set of Socratic questions tailored for medical students based on the clinical case report of the 45-year-old male. These questions are structured to guide clinical reasoning from initial presentation to differential diagnosis and management.

1. Pathophysiology & Clinical Presentation

 * Shortness of Breath (SOB): The patient presents with progressive breathlessness on exertion and bilateral lower limb pitting edema. How do you connect the chronic kidney disease (CKD) history and twice-weekly dialysis to his current complaint of shortness of breath and fluid overload?

 * Knee Pain: He complains of progressive bilateral knee pain for one month. What common secondary metabolic bone diseases or electrolyte disturbances (such as renal osteodystrophy or secondary hyperparathyroidism) should you consider in a patient on long-term dialysis presenting with joint pain?

2. History Taking & Risk Stratification

 * Past Medical History: The patient has a 4-year history of hypertension managed with Amlodipine 10 mg and has been on dialysis for 2 years. Given this timeline, which condition typically precedes and accelerates the other—hypertension causing CKD, or CKD driving resistant hypertension?

 * Review of Systems: The history notes a loss of appetite and disturbed sleep, but no history of burning micturition, hematuria, or fever. Why is the absence of acute urinary symptoms or hematuria diagnostically significant when evaluating a patient with established advanced CKD?

3. Physical Examination & Clinical Signs

 * Vitals & Systemic Exam: His blood pressure is recorded at 110/90\text{ mmHg} with a pulse rate of 90/\text{min}, and respiratory examination reveals reduced air entry with a dull note.

   * Given his history of hypertension and fluid retention, how would you interpret a blood pressure reading of 110/90\text{ mmHg} in this specific clinical context?

   * What does a dull percussion note and reduced air entry suggest regarding his respiratory exam findings?

4. Diagnostic Evaluation & Management

 * PICCLE & General Evaluation: The case mentions specific findings under the "PICCLE" mnemonic and general examination. How do baseline neurological and general assessments help rule out acute uremic encephalopathy in chronic renal failure patients?

 * Next Steps: Given the provisional diagnosis of Chronic Kidney Disease (CKD), what immediate laboratory investigations (beyond standard renal function tests) and imaging modalities would you order to assess his current fluid status, electrolyte balance, and cardiovascular complications?