42 yr M with swelling

A 42 yr old male patient from Huzurnagar autodriver by occupation came with chief complaints of 

swelling at Gluteal region since 25 days and fever since 26 days.

HOPI:

Patient was apparently asymptomatic 8 years back then he had giddiness for which he consulted the local doctor and diagnosed as Hypertension. Since then he is on regular medication for Hypertension. 

2 years back he developed fever and pedal edema.Then he went to local hospital.Then on investigations he came to know that his creatinine levels are increased to 4mg/dl. For which he took medication .Symptoms subsided.

On 14/1/22 He had fever with chills

On 15/1/22 He noticed that he had swelling over inferiomedial part of left Gluteal region and perineal region associated with pain.

On 19/1/22 it was drained by local RMP.On investigations he came to know that his creatinine levels were raised. 

Then on 21/1/22 He came to KIMS for treatment.On investigations his creatinine were raised.

PAST HISTORY:

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

No history of DM,Asthma,Thyroid disorders.

PERSONAL HISTORY:

Diet         : Mixed

Appetite  : Normal

Bowel and bladder movements: Regular 

Sleep        : Adequate

Addictions:

 Alcohol consumption occasionally since 20 years. 

Stopped smoking 10 years ago.

GENERAL PHYSICAL EXAMINATION:

Patient is conscious,coherent,cooperative. Moderately built and nourished. Well oriented to time, place and person.

Pallor              - No

Icterus             -No

Cyanosis         -No

Clubbing          - No

Lymphadenopathy - No

Edema              - No

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- nad

2D ECHO

USG PERINUM (21/1/22)

USG PERINEUM AND SCROTUM(27/1/22)

INVESTIGATIONS:

5/2/22

LIVER TESTS:

Direct Bilirubin : increased to 0.28mg/dl (0.1 -0.2)

Alkaline phosphate: increased to 315 IU/L (53 -128)

Albumin  : decreased to 3.04 g/ dl 

(3.5-5.2)

RENAL FUNCTION TESTS:

Urea   : increased to 103mg/dl  (12-42)

Creatinine : increased to 5.9mg/ dl 

(0.9 -1.3)

Uric acid : increased to 11mg/dl (3.5-7.2)

Phosphate : increased to 5.4 mg/dl 

(2.5-4.5)

HAEMOGRAM:

Haemoglobin: decreased to 9.7 ( 13-17)

Lymphocytes: decreased to 16 (20-40)

RBC Count   : decreased to 3.26M (4.5-5.5)

8/2/22

HAEMOGRAM:

Haemoglobin: decreased to 8.8

RBC     : decreased to 2.94M

MCHC : decreased to 31.4 (31.5- 34.5)

PROVISIONAL DIAGNOSIS:

CKD secondary to Gluteal abscess. 

PLAN OF TREATMENT:

Fluid restriction less than 1L /day

Salt restriction less than 2.4g/day

T.PAN 40mg PO/OD

T.NODOSIS 500mg BD

T.OROFER  PO/OD

T.AMLONG 5mg PO/OD

T.SHELCAL 500mg/OD