GENERAL MEDICINE Case presentation 1.
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Date of admission: 04 - 08- 2021
A 45 year old female came to the casualty with complaints of snake bite 7 days back.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic one week back. Then on Wednesday,patient was alleged to be bitten by snake( Russell viper) on right foot and taken to local hospital for treatment in 1hr and ASV was administered.
She was fine for one day. Then she complains of swelling on right lower limb and went to local hospital for which ointment was advised.
The swelling subsided eventually. After 3days, patients present with a 2-3 bilious vomiting with severe abdominal pain.
There is no history of necrosis around the bite.
No H/0 photophobia, phonophobia.
No H/0 of chest pain, palpitation and syncopal attack.
No H/0 of shortness of breath.
No H /0 of pedal edema .
PAST HISTORY:
No H/O of HTN, CAD, asthma, TB, epilepsy, DM
No history of surgeries and blood transfusion in the past.
FAMILY HISTORY:
There is no history of similar complaints in the family. There is no history of cancer or sudden death in the family.
PERSONAL HISTORY:
Patient takes mixed diet and has normal appetite , adequate sleep,Bowel and bladder movements are irregular { constipation}. Normal micturition ,No addictions.
TREATMENT HISTORY
Patient had not undergone any treatment prior. She is not allergic to any known drug.
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative well oriented to time and place.
Moderately built.
There is no signs of icterus, clubbing, cyanosis and generalized lymphadenopathy.
There is no pedal and bipedal edema.
VITALS:
Temperature : 98°F
Bp: 150/90
Pulse rate : 96bpm
Respiratory rate: 24cpm
Spo2: 99% at room temperature
GRBS: 180mg %
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
S1 and S2 sounds are heard
RESPIRATORY SYSTEM:
Postion of trachea is central
Bilateral air entry- positive
No wheezing sounds
ABDOMEN:
Abdomen is distended and tender.
No palpable mass
CENTRAL NERVOUS SYSTEM:
Patient is conscious
Speech - Normal
No neurological deficits.
PROVISIONAL DIAGNOSIS:
Diagnosed as acute kidney injury with thrombocytopenia.
INVESTIGATIONS:
TREATMENT:
1. Foley's catherization for output monitoring
2. Oral fluids 3lites/ day
3.injection lasix 40mg / BD
4. Strict I/0 monitoring
5. Inj PAN iv/ OD
6. Inj zoffer 4mg/ iv
7. Inj Buscopan IM/ BD.
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