Final short case
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42 year old male,autodriver by occupation came with chief complaints of swelling at the genital region since 6 days fever & shortness of breath since 1 week
History of present illness: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
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
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
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