A 40 yrs old male came to hospital with snake bite

 

Hi I am,Niteesh Gangina (roll no:81), 5 th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.

A 40 yrs old male resident of Nalgonda came to hospital due to snake bite 

Chief Complaints:

Bilateral loin pain since 3days.

History Of Presenting Illness:

Patient was apparently asymptomatic 7days back then he sustained snake bite (with Russell viper) on left ring finger while working in the fields,visited local hospital and managed symptomatically. 

C/O bilateral loin pain,insidious in onset ,intermittent,gradually progressive,pricking type ,non radiating,aggravates on lying down.

He has low grade fever,Nausea and vomiting.

Not a known case of Burning Micturition,decreased or increased urine output.

 No history of cough,cold,body aches,chest pain.


Past History:

N/k/c/o diabetes HTN,Epilepsy,Tuberculosis,CAD,CVA

Personal History:

Diet : Mixed 

Appetite : Normal

Sleep : Normal

Bowel and bladder moments :Regular 

Addictions: chronic alcoholic since 20years.

Tobacco smoking since 20years.

Family History:

Not significant 

General physical examination:

Patient is conscious ,coherent,cooperative and well oriented to time, place and person.

Well built and nourished.

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent 







Vitals:

Temperature - 98*F

PR :- 98beats per minute 

BP :- 130/100mm Hg

RR:-18 cycles per minute


Systemic examination:


Per Abdomen:

Shape of abdomen-distended

Umbilicus -inverted

Abdomen moves accordingly with respiration.

No sinuses/scars 

Swelling in left lumbar region

Abdomen is soft,tenderness in bilateral loin region.

Lipoma measuring 6x4x3cm associated with pain.

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat felt in 5th intercostal space.


Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

Palpation:

All the inspectory findings are confirmed.


Central Nervous system:


Conscious and coherent 

Cranial nervers -normal


Tone                 Rt                  Lt

UL                     N                   N

LL                      N                   N


Power               Rt                  Lt


UL                    5/5                 5/5

LL                     5/5                 5/5

Provisional diagnosis:

Acute kidney injury with h/o snake bite.

Treatment:


Inj Optineuron 1ampoule in 1500ml NS IV/OD


Inj Zofer 4mg IV/SOS


Inj Tramadol 100mg in 100ml NS IV/SOS


IV Fluids @NS 75ml/hr

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