Final short case

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs

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