Case discussion of a 35 y/o Male with Snake Bite

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Case discussion of a 35 y/o Male with Acute Tubular Necrosis

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

CHIEF COMPLAINT

A 35 year old male was referred to our hospital for dialysis after an incident of snake bite 3 days ago.

HISTORY OF PRESENTING ILLNESS

Normal Routine: The patient is a farmer by occupation. He wakes up at 5 am. Freshen up and has breakfast (south Indian cuisine) along with his wife and school going children, a daughter who is 14 y/o and a son who is 10 y/o by 7 am. Goes to his paddy field, which is right beside his home, at 9 am. At around 1-2 pm he has lunch in his field itself. Comes back home at 5 pm. Takes bath and sleeps by 9 pm.

Snake bite incident: On 19th of October, the patient went to his field early to take a stroll at 6 am. At around 6:30 am he felt a prick on his right ankle. At first he didn’t identify it as a snake. After another 10 mins or so he checked the prick and noticed marks similar to snake fangs. He got hysteric and called his brother.
His brother took him to a person he knew who gave him an ayurvedic medicine Chatlakasayam (A Vernacular medicine).
After 2 hours he was taken to a government hospital where he was given anti-snake venom. He stayed at that hospital for 3 days.
There he developed Acute Tubular Necrosis for which he was referred to our hospital for dialysis.

The Pain was initially at the site of bite on the right ankle that was of burning and throbbing type. After a day it extended up till the knee. After 4 days it extended up till the right chest.
The patient has developed cellulitis and regional edema in his right limb extending up till his knee.
Patient also has Ptosis of right eye which started as a heaviness in his lid after the snake bite. It became prominent while they were going to the hospital (2 hours later). It persisted through the night. Started reducing the next day.
No complaint of shortness of breath, cough, cold, palpitations

PAST HISTORY

Not a K/C/O Diabetes, Hypertension, Asthma, Thyroid dysfunction, tuberculosis or any other Chronic Illnesses

FAMILY HISTORY

Insignificant

PERSONAL HISTORY

Diet : Mixed
Appetite : Normal
Sleep : Inadequate
Bowel and Bladder movements : Regular
No addictions
No allergies

GENERAL EXAMINATION

The patient is conscious, coherent and cooperative
Moderately built and well nourished
Pallor : Present
Icterus : Absent
Cyanosis : Absent
Clubbing : Absent
Lymphadenopathy : Absent
Edema : Present on Right leg

SYSTEMIC EXAMINATION

RESPIRATIOY SYSTEM : Normal Vesicular Breath Sounds Audible, Bilateral air entry present, trachea centrally positioned
CVS : S1 and S2 Heard, No murmurs
PA : Soft, Tenderness on left side of abdomen, extending from lower limb up till the left side of the chest, No Organomegaly present
CNS : Intact

LOCAL EXAMINATION

RIGHT LIMB: SNAKE BITE AT THE LATERAL ASPECT OF THE ANKLE AND CELLULITIS EXTENDING UP TILL THE KNEE WITH LOCAL RISE OF TEMPERATURE