35 yr old male with Acute Tubular Necrosis.

KP PRANAY, 9th SEM MBBS

ROLL NO.: 70

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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 the hospital for dialysis after an incident of snake bite 3 days ago. 

HISTORY OF PRESENTING ILLNESS:  

 

Patient was apparently asymptomatic 3 days back then he had a snake bite on his right ankle while he is in his field. He was taken to the government hospital by his brother and given treatment with anti snake venom for 3 days. He was referred to our hospital for dialysis.Initially there is Pain at the site of bite and after 4 days the pain started at the right chest.The patient developed oedema in his right limb till his knee. No complaint of shortness of breath, cough, cold, and palpitations.

PAST HISTORY 

Not a known case of Diabetes, Hypertension, Asthma, tuberculosis or thyroid dysfunction.

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

1. RESPIRATIOY SYSTEM : Normal Vesicular Breath Sounds Audible, Bilateral air entry present, trachea centrally positioned 
2. CVS : S1 & S2 Heard, No murmurs
3. PA : Soft, Tenderness on left side of abdomen, extending from lower limb up till the left side of the chest, No Organomegaly present 
4. 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

RIGHT EYE PTOSIS

VITALS

Blood pressure: 110/80 mmHg
Temperature: 98.5°F
Pulse: 86 bpm
Respiratory rate: 15 cpm
SpO2: 99% on room air

INVESTIGATIONS:

22/10/2021

23/10/2021

ECG:

USG:

DIAGNOSIS:

Acute Tubular Necrosis secondary to a snake bite with Right Lower limb cellulitis. 

TREATMENT :

Day 1 

1 session of hemodialysis for 2 hours along with packed red blood cells transfusion.

Surgery referral and dressings done for rt lower limb cellulitis. 

Day 2 

1 session of hemodialysis done for 2 hrs 

Dressings done for rt lower limb cellulitis

Fluid restriction <1 litre/day

Salt restriction <2.4g/day

Tab Pantop 40mg/PO/OD

Tab Zofer 4mg/PO/SOS

Day 3 

Dressing for cellulitis

Fluid restriction <1 litre/day

Salt restriction <2.4g/day

Tab Pantop 40mg/PO/OD

Tab Zofer 4mg/PO/SOS