Final Practical Short Case

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A 42 year old male,autodriver by occupation came with chief complaints of 1)swelling at the genital region since 6 days

2)fever & shortness of breath since 1 week 

The patient was apparently asymptomatic 8 years back then he had giddiness ,for which he went to local hospital and was diagnosed with hypertension.He was on regular medication.

2 years back he developed fever and pedal edema, for which he went to local hospital and on routine investigations he came to know that his creatinine was 4 mg/dl. He was given medication for the same, and the symptoms subsided.

Presently,he complains of swelling in the perineal region from 6 days, associated with pain.It was drained by local RMP 4 days back.

PAST HISTORY 

K/C/O HTN since 8 years. On regular medication (tab.telma 40 mg)

PERSONAL HISTORY

Diet - mixed

Appetite - normal 

Sleep- adequate

Bowel and bladder - regular

Addictions- consumes alcohol regularly since 20 years.

GENERAL PHYSICAL EXAMINATION 

Patient is conscious, coherent, cooperative, moderately built and nourished.

No pallor,icterus ,cyanosis,clubbing, lymphadenopathy,pedal edema 

Gluteal Abscess

VITALS

Bp- 130/90mm hg

Pr- 92 bpm

Rr- 18 cpm

Spo2- 98%

Grbs- 112 mg/dl

Systemic examination

Cvs-S1,S2 +

Rs-Bae+,nvbs+

P/A- soft ,nontender

Cns- No abnormality detected

Surgery Refferal

USG  PERINEUM AND SCROTUM

PROVISIONAL DIAGNOSIS:

Acute Kidney Injury with Gluteal Abscess.

PLAN OF TREATMENT

IVF -NS,RL @75 ml/hr

INJ.LASIX 20 mg IV /BD

INJ.AUGMENTIN 1.2 GM IV/BD

TAB.AMLONG 5MG OD

TAB.OROFER XT OD

TAB.NODOSIS 500 mg BD

TAB.PAN 40 MG OD

TAB.SHELCAL 500 mg OD