60 year old male AKI on CKD

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60 yr old male,tailor by occupation not working since 3 yrs c/o sob since 3 days,pedal edema since 3days,chest pain since 2hrs.

HOPI - pt was apparently asymptomatic 30yrs ago diagnosed with dm,htn 
7yrs ago c/o b/l pedal edema,decreased urine output diagnosed with heart failure 
10/21 -pt came to our hospital with sob,pedal edema was diagnosed and treated as hfpef,crf,grade 2 bph.

Since 3days c/o sob,pedal edema,chest pain since 2hrs 

No h/o fever,cold,cough 
K/c/o DM,HTN
 
Personal history:
Diet -mixed 
Appetite-normal
Bowel and bladder-regular 
Sleep-adequate 
Alcoholic from 25yrs and he stopped 5yrs back and occasional smoker

GENERAL EXAMINATION:
Pallor -present 
Pedal edema-present 
No cyanosis,icterus,clubbing,lymphadenopathy 

Vitals:
Bp-130/80mmhg
PR-120
Temp-afebrile 
Spo2- 98% at room air 

SYSTEMIC EXAMINATION:
CVS - s1s2 heard 
RS - BAE present 
P/A - soft,non tender
CNS- NAD

PROVISIONAL DIAGNOSIS:
Chronic renal failure 
HFPEF(EF - 52%)
K/c/o DM and HTN since 30yrs
Grade 2 prostatomegaly 

Clinical pictures:







Treatment:

1. Fluid restriction < 1.5 L/ day
2. Salt restriction <2g/ day
3. Inj. LASIX 40 mg iv/ tid
4. Tab. Ecospirin - AV (75/70) po/ hs
5. Tab. Cardibas 3.125 mg po/ bd
6. Tab. Shelcal po/ od
7. Tab. Nodosis 500 mg po/ bd
8. GRBS monitoring 4th hourly 
9. Inj. HAI s/c after informing doctor
10. O2 inhalation to maintain spO2 >90 %

Day 1:

S- SOB (mild), productive cough

O- Bp-130/80mmhg
     PR-120
     Temp-afebrile 
     Spo2- 98% at room air 
     CVS - s1s2 heard 
     RS - BAE present 
     P/A - soft,non tender   
     CNS- NAD

A- AKI on CKD

P- Fluid restriction < 1.5 L/ day
    Salt restriction <2g/ day
    Inj. LASIX 40 mg iv/ tid
    Tab. Ecospirin - AV (75/70) po/ hs
    Tab. Cardibas 3.125 mg po/ bd
    Tab. Shelcal po/ od
    Tab. Nodosis 500 mg po/ bd
    GRBS monitoring 4th hourly 
    Inj. HAI s/c after informing doctor
    O2 inhalation to maintain spO2 >90 %

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