Case discussion

 B.VAISHNAVI

3RD SEMESTER

ROLL NO. 22

This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

A 45 year old female farmer by occupation presented with chief complaints of abdominal pain and vomiting since 4 days, headache since 1 day. 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 days back. On Wednesday around 7:30 pm, pt alleged to be bitten by snake on right foot went to the local hospital, she is fine for 1 day. Had  swelling of right lower limb, went to the local hospital ( ointment  given)swelling subsided.  Complained of vomiting(2-3 episodes), bilious ( food as content) since 4 days. Pt complained  of abdominal pain since 4 days, squeezing type, in the periumbilical region, aggregated with vomiting, no radiation. Abdominal distension following food consumption. 

Headache since 1 day

No photophobia, phonophobia, lacrimation, diplopia

No complaints of chest pain, palpitations

No complaints of SOB,  PND

No complaints of burning micturition

No complaints of pedal edema, puffiness of face




HISTORY OF PAST ILLNESS:

No h/o of similar complaints in the past

N/K/C/O DM, Hypertension, epilepsy, TB

PERSONAL HISTORY:

Appetite normal

Mixed diet

Bowel movements- constipation

Bladder movements- normal

No addiction

FAMILY HISTORY:

Not significant

DRUG HISTORY:

No known allergies

GENERAL EXAMINATION:

Patient is conscious, coherent,  coorperative 

Moderately built and moderately nourished

Pallor present

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No edema

VITALS:

Temperature: afebrile

PR:96 bpm

RR: 24 cpm

BP : 150/90 mm Hg

SPO2: 99%

GRBS: 180mg%

SYSTEMIC EXAMINATION:

CVS:

S1, S2 Heard

No thrills 

No murmurs

RESPIRATORY SYSTEM:

Vesicular breath sounds heard

No dyspnoea

no wheeze sounds heard

ABDOMEN:

shape - scaphoid

Tenderness present in the periumbilical region

No palpable mass

Hernial orifices are normal

Free fluid absent

Liver and spleen - not palpable

Bowel sounds heard

CNS:

Pt is conscious, coherent, coorperative

Speech -normal

No signs of meningeal irritation

No abnormality detected

INVESTIGATIONS:

ELECTROCARDIOGRAM:











02/08/2021

ULTRASOUND REPORT:






COMPLETE BLOOD PICTURE:

Hb- 8.5 gm%

RBC - 3.3 m/ cu mm

WBC- 9000/ cu mm

Platelets- 63,000/ cu mm

Neutrophils- 66%

Lymphocytes- 30%

Eosinophils- 02 %

Monocytes- 02%

Basophils- 00%

RANDOM BLOOD SUGAR :113 mg/dl

SERUM CREATININE: 1.4 mg/dl

SERUM URIC ACID : 7.2 mg/dl

BLEEDING TIME- 2 min 15 sec

CLOTTING TIME- 4 min 45 sec


LIVER FUNCTION TEST:

Total bilirubin- 1.0 mg/dl

Direct bilirubin- 0.2 mg/dl

Indirect bilirubin- 0.8 mg/dl

ALP- 90 IU/L

Total proteins- 6.7 gm

Albumin- 4.5 gm

Globulin- 2.2 gm

SGPT- 34 IU/L

SGOT- 24 IU/L

ABG



03/08/2021

COMPLETE URINE EXAMINATION:



SERUM ELECTROLYTES:





SERUM CREATININE:



BLOOD UREA:



URINE SODIUM:



URINE PROTEIN/ CREATININE RATIO:



05/08/2021

RENAL FUNCTION TEST:



06/08/2021

HEMOGRAM:




PROVISIONAL DIAGNOSIS:

ACUTE KIDNEY INJURY SECONDARY TO ACUTE TUBULAR NECROSIS, SNAKE BITE? TOXINEMIA. 


TREATMENT:

Rx:

IVF 20 NS, 20RL @ 100 ML/DAY

INJ PAN 40 MG IV/OD

INJ ZOFFER 4MG/IV/TID

INJ BUSCOPAN IM/BD

BP/PR/RR/SPO2 - 4TH HRLY

GRBS CHARTING -6TH HRLY

STRICT I/O CHARTING

TAB PCM 650 MG PO/SOS

INJ LASIX 40 MG IV/BD

IF SBP>=100 mmHg




























































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