AKI on CKD with hypertensive urgency

October 1st 2021,
Admission under nephrology department.

Under the guidance of Dr Pradeep sir

65 year old male came with complaints of B/l lower limb edema(pitting type) ,upper limb edema and facial puffiness since 5 days

Hopi : patient was apparently alright 5 days back then he developed b/l pitting type of lower limb edema progressed to upper limb

No history of facial puffiness ,vomitings,loose stools,orthopnea,PND

K/c/o CVA since 2 months recovered within 1week 
K/c/o hypertension since 5 months(on prazosin 5mg)
H/o 2 sessions of hemodialysis in 2013
On examination : 
Pt is c/c/c
No signs of pallor, icterus, cyanosis, clubbing, lymphadenoapathy, edema
Vitals:
Afebrile
PR: 70 bpm, regular
RR: 24 cpm
BP: 220/130 mmHg
SPO2:
AT ROOM AIR-98%
Systemic examination :
 CVS:S1,S2 heard
 Apex beat:5th ICS
Resp:
BAE+
Nvbs heard
Position of trachea- central
P/A: soft, tenderness absent, bowel sounds heard

Provisional diagnosis
Hypertensive urgency with anemia ,anasarca under evaluation ,AKI in CKD with rt sided CVA( 2 months back) andk/c/o HTN 5 months back 

PLAN OF CARE 
1)fluid restriction less than 1.5 liters per day
2)salt restriction less than 2g/day
3)inj.lasix 40 mg lv/bd 
4)Tab.clopidogrel 75 mg / po/od
5) Tab ecospirn 75 mg po
6)TAb.Atrovastatin 10 mg po/od
7)Tab.MET-XL 50 mg po/od
8)Tab.ultracet po/qid/1/2 tablet
9) strict I/o charting
10)Bp monitoring

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