56F FEVER SECONDARY TO L GLUTEAL ABSCESS WITH AKI(PRERENAL) WITH CHOLELITHIASIS WITH GB SLUDGE WITH GRADE II FATTY LIVER WITH HEPATOMEGALY AIYH HTN SINCE 1 YEAR

TEJASWINI MARISA(INTERN)

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A 56 year old female came with c/o pain abdome since 10days
C/o generalised weakness since yesterday morning(13/3/23)
Hopi:
Patient was apparently alright 10 days back then she had fever for 3 days which is low grade, intermittent, associated with chills and rigors 
No h/o vomitings, loose stools
On 3rd day of fever there is SOB which is insidious in onset decreased by lying down 
No orthoponea
No PND
H/o decreased urine output for 1 day amd went to local hospital and took treatment and diagnosed with AKI 
c/o pain abdomen since 10days, epigastric and right hypochondrium
h/o Nausea present 
Past history:
K/c/o HTN since 1 year on TELMA H 40/12.5
He is not a k/c/o DM II,  CVA, CAD, ASTMHA
GENERAL EXAMINATION:
pt is c/c/c
pallor present 
No icterus, cyanosis, clubbing, generalised edema or lymphadenopathy
Vitals 
bp-90/60
Pr -92bpm
RR: 22
Spo2 -97% @ RA
GRBS: 169mg/dl
Systemic examination:
Rs-bilateral air entry present 
      Nvbs 
CVS -s1 S2 heard
No murmurs 
CNS: NFND
P/A:
Inspection:
Obese abdomen
No scars, sinuses, engorged veins
No visible peristalsis
Palpation:
No local rise of temperature
tenderness in right hypochondrium and epigastrium
Liver palpable 2cm below the coastal margin
No other palpable mass
Hernial orifices normal
Percussion:
Resonant note
Auscultation:
Bowel sounds heard

Local examination
On 14/3/23
On 15/3/23

a ulcer of size 4x3cm noted over L gluteal region

Per vagina
Grade 1 prolapse

INVESTIGATIONS:
CXR PA VIEW
ECG
2D ECHO
USG ABDOMEN
USG OF L BUTTOCK
REVIEW USG


Diagnosis - 
Fever secondary to L gluteal abscess 
With AKI(prerenal)
with cholelithiasis with gallbladder sludge
With grade II fatty liver with hepatomegaly with HTN since 1 year

Treatment:
1.NBM till furthur order
2.INJ PIPTAZ 2.25gm IV/TID
3.INJ METROGYL 500mg IV/TID
4.IV FLUIDS  1unit NS, RL, DNS @ 100ml/hr
5.INJ PAN 40mg IV/OD
6.INJ ZOFER 4mg IV/SOS
7.INJ NEOMOL 1gm IV/SOS
8.TAB PCM 650mg PO/TID
9.T CINOD 10mg po/od

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