55 year old male cc regular dialysis

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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.

The patient is a 55-year-old male resident of Kodada occupation by labourer

Chief complaints 

regular dialysis session 

HISTORY OF PRESENTING ILLNESS 

He presented with multiple complaints, including a history of alcohol use for 10 years until 2006 when he was between 25 to 40 years old. Stopped alcohol consumption upon taking up the ayyappaswamy ritual completed the pilgrimage to Ayyappa Swamy approximately 50 times, between the ages of 25 to 30 when he worked as a toddy tapper. During these days he experienced severe lower limb pains upto the level of ankles which were insidious in onset and gradually porigeessive in nature associated with pedal edema ,pedal edema that worsens upon walking but is relieved by taking NSAIDs.,for which patient used to take NSAIDS prescribed by rmp in a regular basis (weekly twice on average ),he also received injection at the RMP clinic for the same on several occasions ,

His kidney failure was incidentally found and He has been experiencing high blood sugar for the last 4 years which was incidentally found out through investigations done in order to treat his lower limb pains 

shortness of breath for the past days , which improved with RMP medication. He also reported feeling giddy on regular basis (one episode today in the morning ) and having decreased urine output associated with urinary hesitancy for a year

PERSONAL HISTORY 

The patient has two sons, elder son is married ,one married daughter who is pursuing PhD in pharmacy in hyd , and younger son who is 30 years .

SURGICAL HISTORY 

He has a surgical history of hydrocele which he developed on lifting heavy jute sacks along with hydrocele he had also developed umbilical hernia (not treated ,asymptomatic ever since )and cataract surgery in 2015. 

Additionally, he has undergone 10 dialysis sessions in August.

PAST HISTORY 

K/c/o type 2 DM since 4 years 

History of hydrocele and umbilical hernia 10 years back 

FAMILY HISTORY 

No similar complaints in family 

TREATMENT HISTORY 

calcitriol tablets 

Oha’s since 4 years 

GENERAL EXAMINATION 

PALLOR -present in lower palpebral conjunctiva 

ICTERUS -absent 

CYANOSIS  -absent

CLUBBING  -absent

LYMPHADENOPATHY  -absent

PEDAL EDEMA -present upto ankles ,pitting  type