A 62-year-old male comes to your primary care office with shortness of breath that has progressively worsened over the last three weeks. His medical history is significant for hypertension, diabetes and knee pains. He takes ibuprofen for his knee pains, he reports, ‘Without it, I can’t function’. He started on hydrochlorothiazide 6 months ago. Two months later, his doctor added one more ‘blue pill’ to control his blood pressure because the first pill was not completely effective. He can’t remember the name of the ‘blue pill’. Last month, he was started on a third pill because the first two medications could not bring his blood pressure to a normal level. His current medications are hydrochlorothiazide 25 mg, a blue pill, lisinopril 20 mg, insulin of unknown units per day and ibuprofen 800 mg three times a day. His temperature is 99 ⁰ F, heart rate is 62 beats per minute, respiratory rate is 17 breaths per minute, and blood pressure is 165/95 mm Hg. Physical examination reveals an anxious patient; on auscultation fine crackles at the bases of the lungs, audible bruit on both sides of his abdomen, and bilateral pitting edema. Laboratory tests show elevated serum creatinine, elevated renin, and hypokalemia. Chest x-ray shows increased interstitial markings, butterfly pattern of distribution of alveolar thickening, and increased blurriness of vascular outlines. Abdominal ultrasound revealed two small hyperechoic kidneys. What is the next best step in the management of this patient?
