General medicine final practical examination - short case

 February 9th, 2022

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. This e- log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

Date of administration: 21 st jan 

A 45 yr old male came to the opd with chief complaint of fever since 1 week,swelling  at the genital region since 6 days

History of present illness :

Patient was apparently a symptomatic  8 years back then he was  diagnosed with hypertension & he was on regular medication . 

2 years back he developed fever & pedal edema & he went to local hospital & on routine examination the creatinine levels was 4 mg/dl  and he used medication for that 

Then patient came to the opd with chief complaint of swelling in genital region from 6 days  which is associated with pain & it was drained by local doctor 4 days back. 

Past history :

Diet :mixed 

Appetite : normal 

Bowel & bladder movements : regular

Sleep : adequate

Addictions : regular alcoholic since 20 yrs 

Family history:

No relevant family history

General examination :

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

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








Vitals :

Bp:130/90mm hg

Pr:92bpm

Rr:18cpm

Spo2:98%

Grbs:112mg/dl

Systemic examination:

CVS :S1&S2  +

RS :BAE +, NVBS +

P/A : soft & tender

CNS :No abnormality detected 

Provisional diagnosis :

Acute kidney injury on gluteal abscess 

Treatment :

IVF:NS , RL@75ml/hr

INJ:LASIX 20 mg IV/BD 

INJ:AUGMENTIN 1.2 GM IV/BD 

TAB :AMLONG 5 mg OD 

TAB : OROFER XT OD

TAB: NODOSIS 500mg/bd 

TAB :PAN 40 mg OD 

TAB : SHELCAL 500 mg OD 








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