Differential Diagnosis

The patient's presentation is complex, with a combination of cardiovascular, neurological, and respiratory symptoms. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Chronic Kidney Disease (CKD) with associated Hyperparathyroidism and Anemia: The combination of high blood pressure, fatigue, breathlessness, and elevated NT-PROBNP suggests cardiovascular involvement, possibly due to CKD. The strong tremor, restless legs syndrome, weakness, and involuntary muscle spasms could be related to hyperparathyroidism (secondary to CKD) and anemia, which are common in advanced CKD.

• Other Likely Diagnoses

  • Heart Failure: Elevated NT-PROBNP and symptoms like breathlessness and fatigue suggest heart failure, which could be a consequence of long-standing hypertension.
  • Sleep Apnea Complications: Although the patient uses CPAP, poor adherence or residual sleep apnea could contribute to fatigue, hypertension, and cardiovascular strain.
  • Anemia of Chronic Disease: This could explain the fatigue, weakness, and shortness of breath, especially if there's an underlying chronic condition like CKD.

• Do Not Miss Diagnoses

  • Pheochromocytoma: Although less likely, this condition can cause resistant hypertension, tremors, and palpitations. Missing this diagnosis could be deadly due to the risk of hypertensive crises.
  • Thyroid Dysfunction: Both hyperthyroidism and hypothyroidism can cause tremors, fatigue, and muscle weakness. Thyroid storm or myxedema coma are life-threatening conditions that must not be missed.
  • Multiple Myeloma: This could lead to hypercalcemia (causing weakness and muscle spasms), anemia, and renal failure, explaining many of the patient's symptoms.

• Rare Diagnoses

  • Wilson's Disease: A genetic disorder leading to copper accumulation, which can cause neurological symptoms (tremors, muscle spasms), liver disease, and psychiatric symptoms.
  • Friedreich's Ataxia: An autosomal recessive genetic disorder that affects the nervous system and heart, leading to progressive damage and symptoms like ataxia, muscle spasms, and heart disease.
  • Acromegaly: Excess growth hormone can lead to hypertension, sleep apnea, and muscle weakness, among other symptoms, though it's less likely given the absence of classic features like acral enlargement.