General medicine case 6

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October 26, 2021

37 YEAR OLD MALE FARMER BY OCCUPATION

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.

A 37 y male Farmer came to casualty with c/o

decreased urine output since 4 days

swelling of RT lower limb since 4 days

HISTORY OF PRESENT ILLNESS:

patient was apparently asymptomatic 4 days back then he had a snake bite while he working in the farm around 6:00 am ,he didn't see the snake and was taken to a near by local hospital around 9:00 am and given treatment with universal ASV for 3 days and refered to our hospital I/V/o dialysis as his creatinine was 6.1 

no c/o shortness of breath , cough , cold , palpitations .

h/o 1 PRBC transfusion with 2 sdp transfusion done on 21-10-21.

Edema of right leg

HISTORY OF PAST ILLNESS:

not a K/C/O EM/HTN/TB/ASTHMA.

TREATMENT HISTORY:

no significant treatment history

FAMILY HISTORY:

no significant family history

PERSONAL HISTORY:

Appetite is normal

Mixed diet 

Sleep is adequate

Bowel and bladder movements-normal

No addictions

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and co-operative.

VITALS:

temp- 98.5°f

PR- 99/min

RR-18/min

BP- 110/80 mmHg

SPO2- 98% at room air

grbs-151mg %

SYSTEMIC EXAMINATION:

CVS-s1s2 heard

RS- BAE +

ABD-NAD

CNS- NAD

PROVISIONAL DIAGNOSIS- AKI 2° TO SNAKE BITE( NEUROTOXIC)

 ATN WITH RT LOWER LIMB CELLULITIS?

INVESTIGATIONS:

ECG:

USG:

X-ray Chest:

USG-Abdomen:

Treatment : 

Day 1 

1 session of hemodialysis for 2 hours along with prbc transfusion

Surgery referral and dressings done for right lower limb cellulitis

Day 2 

1 session of hemodialysis done for 2 hrs 

Dressings done for right lower limb cellulitis

Tab pan 40 mg po/od

Day 3 

Dressing for cellulitis

Tab pan 40 mg po/od

Day 4 

Dressing for cellulitis 

1 session of hemodialysis done 

Tab pan 40 mg po/od

Day 5 

Dressing for right left limb cellulitis 

Tab pan 40 mg po/od 

Tab dolo 650 mg /sos 

Tab zofer po/sos 

SYP ASCORYL 10 ml 

Inj optineuron 1 amp in 100 ml NS /IV /OD

Day 6

Planning for dialysis with transfusion as his hb is 4.9 ( dialysis done with prbc transfusion ) 

Dressing for rightt leftlimb cellulitis 

Inj augmentin 1.2 gm IV/BD

Tab pan 40 mg po/od 

Tab dolo 650 mg /sos 

Tab zofer po/sos 

SYP ASCORYL 10 ml 

Inj optineuron 1 amp in 100 ml NS /IV /OD

Day 7 

Dressing for rightt left limb cellulitis 

Inj augmentin 1.2 gm IV/BD

Tab pan 40 mg po/od 

Tab dolo 650 mg /sos 

Tab zofer po/sos 

SYP ASCORYL 10 ml 

Inj optineuron 1 amp in 100 ml NS /IV /OD