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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