A 80 years old male patient with 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 80 years old patient who is weaver by occupation came to the OPD with chief complaint of shortness of breath since 10 days

History of past illness :

Patient has good state of health in his past. He has no signs of illness until past 10days. 

He has stopped his job as a weaver 5 years back. He remains active through out day. 

Past history :

Not a known case of pulmonary edema, heart failure, hypertension. 

Personal history :

Diet : mixed 

Sleep : disturbed due to breathlessness 

Appetite : normal 

Bowl bladder movements : irregular 

Addictions : no habit of drinking alcohol, smoking, chewing tobacco etc. 

Family history  : 

No significant 

General examination :

Patient is conscious,  coherent,  cooperative  well oriented to time , place ,person. 

No signs of unconsciousness,ascitis,lymphodenopathy, low bp, enlargement of organs. 

 Investigations :

Gall bladder : dilated , wall thickness normal 

Pancreas : N (S/E )

Spleen :  7.4 cm(S/E )

Right Kidney :  6.4 * 3 cm

Left kidney : 5.7 * 2.9 cm 

           Decrease S,  increased  , CND -lost, 

            PCS -nornal 

On palpitation : 

Patient stomach is drawn inside.  No sounds heard. Lower abdomen is stiff due to irregular bowl moments. 

LFT :

TB : 1.27

DB : 0.16

AST :  16 

ALT : 11

ALP : #531

TP : #5.7

RFT : 

Urea : #123

Creatinine : #7,3

Diagnosis  : 

Acute pulmonary edema  , secondary heart failure, secondary hypertension. 

Kidney size has been decreased.