A 34 year old patient with pain and swelling in the right leg

Tondapu Sreelekha, 9th semester

Roll no. – 135

 This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients’ clinical problems with collective current best evidence-based inputs. 

This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome

 

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 diagnosis and treatment plan. 

 

 

Following is the view of my case: (history as per date of admission)

CASE

A 35-year-old male patient, farmer by occupation  came to the OPD with chief complaints of 

• pain and swelling in right leg since 4 days
• decreased urine output since 4 days

 

HISTORY OF PRESENTING ILLNESS

The patient was apparently assymtomatic 4 days back. Then he felt a prick to his leg while working on the farm land  at 6am which he assumed to be due to a thorn and ignored it and went home. 

After coming back home he noticed that there were bite marks on the leg which were consistent with that of a snake. 

At 9am he went to a local hospital. 

TREATMENT HISTORY 

He was given universal ASV in the local hospital for 3 days. 

H/O 1 PRBC transfusion with 2 SDP transfusion.

He was referred to our hospital for dialysis as his creatinine levels were high (6.1) 

PAST HISTORY

No similar complaints in the past.

He is not a known case of diabetes mellitus, hypertension, TB, Asthma and epilepsy. 

PERSONAL HISTORY

• DIET- non- vegetarian 
• APPETITE- normal
• SLEEP- Adequate
• BOWELS- Regular
• MICTURATION- decreased 
• ADDICTIONS- None
• ALLERGIES- None

GENERAL EXAMINATION

The patient was conscious, coherent and cooperative and well oriented to time, place and person.

He was moderately built and moderately nourished.

·         No pallor

·         No icterus

·         No cyanosis

·         No clubbing

·         No generalized lymphadenopathy

.         He has Edema in the right leg till mid thigh. 

VITALS at the time of admission

·        Temperature: febrile

·        Pulse: 99 beats/mins

·        Blood pressure: 110/80 mmHg

·        Respiratory rate: 18 cycles/min

.        SPO2- 98% at room air

.        grbs-151mg %

CVS

·         S1 and S2 heart sounds heard.

·         No murmurs heard.

Respiratory system

·      Bilateral air entry +

 

CNS- Intact

Abdomen

·         Soft and non-tender.

·         Bowel sounds were heard.

·         No organomegaly.

INVESTIGATIONS

22/10/21

24/10/21

X-ray 

ECG

26/10/21

Provisional diagnosis:

AKI 2° to snake bite

?ATN with right lower limb cellulitis

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 

Planning for dialysis with  transfusion as his hb is 4.9 

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