37 year old male farmer by occupation
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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.
A 37 y male Farmer came to casualty with c/o
decreased urine output since 4 days
swelling of RT lower limb since 4 days
pt. was apparently asymptomatic 4 days back then he had a sanke bite while he working in the farm around 6:00 am ,he didn't see the snake and was taken to a near by local hospital around 9:00 am and given treatment with universal ASV for 3 days and refered to our hospital I/V/o dialysis.as his creatinine was 6.1
no c/o shortness of breath , cough , cold , palpitations .
h/o 1 PRBC transfusion with 2 sdp transfusion done yesterday
history of past illness- not a K/C/O DM/HTN/TB/ASTHMA.
no significant treatment and family history
o/e- pt is c/c/c moderately built and nourished
edema of right leg
temp- 98.5°f
PR- 99/MIN
RR-18/MIN
BP- 110/80 MMHG
SPO2- 98% at room air
grbs-151mg %
CVS-s1s2 heard
RS- BAE +
ABD-NAD
CNS- NAD
PROVISIONAL DIAGNOSIS- AKI 2° TO SNAKE BITE( NEUROTOXIC)
? ATN WITH RT LOWER LIMB CELLULITIS
IInvestigations
USG
24/10/21
26/10/21
Xray chest
USG abdomen
27/10/21
S
c/o pain in rt lower limb
c/o cough
One fever spike @ 8 am
Thrombophlebitis present in lt hand
O
Vitals:
Temp- 101 °F
PR-111 BPM
RR-18 cpm
BP-130/80mmHg
SPO2- 97 @ room air
I/O: 1000/1550
Ur-118
Cr-4.3
UA-4.8
Na-132
K-3.6
Cl-94
Serum ldh-1580
28/10/21
Treatment :
Day 1
1 session of hemodialysis for 2 hours along with prbc 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
Tab pan 40 mg po/od
Day 3
Dressing for cellulitis
Tab pan 40 mg po/od
Day 4
Dressing for cellulitis
1 session of hemodialysis done
Tab pan 40 mg po/od
Day 5
Dressing for rt ll cellulitis
Tab pan 40 mg po/od
Tab dolo 650 mg /sos
Tab zofer po/sos
SYP ASCORYL 10 ml
Inj optineuron 1 amp in 100 ml NS /IV /OD
Day 6
Planning for dialysis with transfusion as his hb is 4.9 ( dialysis done with prbc transfusion )
Dressing for rt ll cellulitis
Inj augmentin 1.2 gm IV/BD
Tab pan 40 mg po/od
Tab dolo 650 mg /sos
Tab zofer po/sos
SYP ASCORYL 10 ml
Inj optineuron 1 amp in 100 ml NS /IV /OD
Day 7
Dressing for rt ll cellulitis
Inj augmentin 1.2 gm IV/BD
Tab pan 40 mg po/od
Tab dolo 650 mg /sos
Tab zofer po/sos
SYP ASCORYL 10 ml
Inj optineuron 1 amp in 100 ml NS /IV /OD
Discharge summary
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