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AKI Case
Patient Presentation
Chief complaints are increasing SOB, tachypnea, fatigue, tiredness, anorexia and lower limb edema
HPI
M.Y.M is a 70 years old male patient with history of DM Type II, HTN, class II and HF Stage C and NYHAFC class II, admitted via ER due to HF decompensation subset II. History dates back to 3 days prior to
admission when the patient started to complain from increase SOB , tachypnea , fatigue , tiredness ,
anorexia , lower limb edema which have been gradually worsening over the past 2 days and became
worse over the last day prior to admission.
PMH
1- Diabetes Mellitus type 2 (diagnosed since 1989; and is controlled)
2- HTN (diagnosed since 1985; and is uncontrolled)
3 HF stage C, NYHA –FC Class II (diagnosed since 2005; and is controlled)
4- Positive history of ASA and medical conditions induced gastric ulcer
5- Hypoglycemic episodes, 5 episodes last year, treated at home
6- Have his drugs most days of the week
FH
1-Father with DM and HTN and died of AMI
2-Mother with HTN and breast cancer and died, free healthy history for his brothers and sisters
3- Married and lives at home with his wife
4- Limited social activity
SH
1- Slightly limitation of physical activity, ordinary physical activity results in fatigue, palpitation, and
dyspnea
2- He smoked 2-2 ½ pack per day for 30 years (60-75 pack/year)
3- Moderate caffeine consumption (2-4 cups per day)
4- History of alcohol use; patient is not asked
PTA
Furosemide (Lasix ®) tab PO, 40 mg once daily in the morning
ASA (Aspirin ®) tab PO, 100 mg once daily
Atorvastatin (Lipitor ®) tab PO 20 mg once daily ABT
Candesartan (Atacand ®) tab PO, 8 mg once daily
Metformin (Glucophage ®) tab PO, 850 mg three times daily
NPH / Cryst-Insulin (Mixtard 70/30 ®) Inj SC, 30 U / 40 U / 30 U
Omeprazole (Losec ®) tab PO, 20 mg once daily
Current Meds
Furosemide (Lasix ®) inj IV, 40 mg twice daily according to response, then when the patient is stable,
start furosemide (Lasix ®) tab PO, 40 mg twice daily
Candesartan (Atacand ®) Tab PO, 16 mg once daily
Metformin (Glucophage ®) tab PO, 850 mg three times daily
NPH / Cryst-insulin (Mixtard 70/30 ®) Inj SC, 30 U / 40 U/ 30 U
ASA (Aspirin ®) tab PO, 100 mg once daily
Atorvastatin (Lipitor ®) tab PO 10 mg once daily ABT
Omeprazole (Losec ®) tab PO, 20 mg once daily
Enoxaparin (Clexan ®) inj SC, 40 mg once daily
ROS
General
Patient is agitated and confused
VS
BP 151/94, P 97, RR 24, T 36.8°C; Wt 83 kg, Ht 174 cm; oxygen saturation 84%
Cardiovascular
He dined chest pain, normal ECG, no palpitation, S3 & S4 gallop, elevated JVP, tachycardia
Respiratory
Wheezing, SOB, productive coughs and increase sputum volume. Inspiration crackles during lung
expansion, tachypnea, (+) pleuritic chest pain, pleural effusion, decreased breath sound, use accessory
respiratory muscles, paradoxical chest wall movements
Gastrointestinal
(+) constipation, (+) flatulence, anorexia, bloating, negative nausea and vomiting. No dysphagia, soft and
nontender
Allergies
Skin rash was recorded after taking amoxicillin
Genit / Rect
He denied dysuria, urinary frequency, rectal exam deferred
Dermatology
Normal skin appearance and turgor
Neurology
He denied tremor, numbness, he only complained of headache
Psychology
Loss of appetite
Endocrine
None
Hematology
He denied of having bleeding gums, and bruising
Labs
Na 136 mEq/L
Hgb 11.2 g/dL
AST 29 IU/L
Ca 9.2 mg/L
K 3.5 mEq/L
Hct 34.1%
ALT 22 IU/L
Mg 1.92 mg/L
T. bili 0.8 mg/dL
Phos 4.3 mg/dL
Alb 3.6 g/dL
LDL-C 90 mg/dL
Cl 103 mEq/L
HCO3 22 meg/l
Plt 165 ×
103/mm3
WBC 9.4 ×
103/mm3
BUN (day 1) 29 mg/dL Neutrophil sig% 65.3 × 103/mm3 Basophils% 0.23 × 103/mm3
BUN (day 2) 35 mg/dL Monocytes% 3.9 × 103/mm3
Glu 240 mg/dL
RBC 6.2 × 106/uL
HDL 34 mg/dL
Eosinophils% 0.23 × 103/mm3 TG 190 mg/dL
Plt 165 × 103/mm3
SCr (day 1) 0.96 mg/dL SCr (day 2) 1.31 mg/dL
Scores / Stages / Classes
Pain score = 1, VTE score =3, HF stage C, NYHA-FC class II, HF exacerbation subset II (Warm & Wet
HF), LVEF = 33%