A Case of Acute Kidney Injury Due to Snake Bite

Welcome to my blog! I am Varshitha Kalidindi, a 2nd year medical student. This is an e-log to discuss our patient's de-identified health data after taking informed consent of the patient. It also reflects patient centered online learning portfolio.

I will be looking forward to some feedback and valuable inputs through the comments box provided below. 

I have been given this case 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, diagnosis and treatment plan.

CASE:-

A 38 year old male patient, daily wage labourer, came to the OPD with swelling in right lower limb. The patient was apparently asymptomatic 8 days ago until he got bitten by a snake.

  After the snake bite, he went to a government hospital nearby and was treated with ASV (Adaptive-servo ventilation) for 3 days. After this, he was referred to our hospital and is currently on dialysis.

   At present, the patient mainly complains of cough which started yesterday, burning micturition since today morning and pain in the right lower limb ever since the snake bite, which is radiating throught his entire right limb.

HISTORY OF PRESENT ILLNESS:-

Before the snake bite, this was the routine of the patient:-

The patient wakes up at 5:00am, eats breakfast (usually idli) and goes to work by 9:00. He is a daily wage labourer and his job involves lifting heavy sand bags and bricks. He has lunch at around 1:00pm.

  He finally returns home from work at 5:30pm, which is when he takes a bath, sits and talks with his wife about the day and rests. He then eats dinner and sleeps by 9:00pm. 

He drinks a very good amount of water as well, almost around 3 litres a day. He drinks one litre of water with his dinner at night.

He doesn't drink more than a glass of alcohol a day. He chews tobacco alot.

The snake bite occured 8 days ago at 6:00am in the morning at thimmannagudam, where he lives. He was apparently walking around when he noticed that he stepped on something, immediately followed by a bite on his right foot. He couldn't see what it was, so he wasn't sure it was an insect bite or a snake bite. He noticed that there were 3 fang marks on his foot which led him to the conclusion that it was a snake bite.

After the snake bite, he noticed that his right limb (the side of the bite) swelled up almost immediately to a very considerable extent, almost 3 times it's initial size (according to the patient). He immediately went to a Yellamma temple nearby, where they tied some herbs to the wound and gave a herbal tonic. This didn't reduce the swelling.

     The patient then immediately went to a government hospital nearby and he was given treatment with ASV for 3 days, but this didn't reduce the swelling in his leg either. He also had diminished vision. He was finally referred to our hospital.

At our hospital, he feels very satisfied that his swelling has reduced significantly. From yesterday, however, he has been experiencing a lot of cough and difficulty in breathing at night. He took cough syrup but it didn't help reduce the cough. The cough is occuring so frequently, which is causing his whole chest to ache and he feels shortness of breath. His throat is also burning from excessive coughing and is making it difficult for him to eat food. His appetite has thus reduced. He is able to drink water.

   He also complains of burning micturition from today morning, which is also causing him a lot of discomfort. It could be catheter associated. His leg is also still painful but the swelling has reduced significantly. It is still difficult for him to walk because the pain is radiating throughout his limb, even his thigh. This is making it difficult for him to walk.

He just wants these main 3 symptoms to subside so that he can go home: the pain in the leg, the cough and the burning micturition.

HISTORY OF PAST ILLNESS:-

Not a known case of hypertension, diabetes mellitus, tuberculosis, epilepsy, CVA

TREATMENT HISTORY:-

No significant treatment history

PERSONAL HISTORY:-

Appetite: reduced

Diet: non-vegetarian

Bowels: regular

Micturition: reduced

Habits: He is an alcoholic, chews tobacco

FAMILY HISTORY:-

No family history of diabetes, hypertension, heart disease, stroke,cancer, tuberculosis, asthma

PHYSICAL EXAMINATION:-

No pallor, icterus, cyanosis, clubbing of fingers/toes, lymphadenopathy.

 Oedema was seen in right foot.

VITALS:-

Temperature: 98.5

Pulse rate: 99bpm

Respiratory rate: 18 breaths per minute

BP: 110/80 mmHg

SPO2: 98%

GRBS: 151mg%

SYSTEMIC EXAMINATION:-

CVS: S1, S2 sounds heard

Respiratory system: Position of trachea is central, vesicular breath sounds heard

Abdomen: Scaphoid

CNS: The patient was conscious and alert with normal speech.

DIAGNOSIS:-

AKI (Acute Kidney Injury) secondary to snake bite (nephrotoxic)

?ATN (Acute tubular necrosis) with right lower limb cellulitis.

INVESTIGATIONS:-

Hemogram 27.10.2021:-

Findings:-                                                                   

ECG:-

Urine sodium:-

SARS-COV-2 Qualitative PCR:-

Dengue rapid test:-

Urinary potassium:-

Urinary chloride:-

LFT 22.10.2021:-

RFT 22.10.2021:-

ESR:-

Hemogram 21.10.2021:-

Blood grouping and Rh type:-

CUE:-

APTT:-

PT:-

HIV 1/2 Rapid test:-

HBsAg-RAPID:-

Anti HCB Antibodies-RAPID:-

ABG 22.10.2021:-

RFT 22.10.2021:-

ABG 22-10-2021:-

RFT 22-10-2021:-

Blood urea:-

Serum creatinine:-

Uric acid serum:-

Serum electrolytes (Na, K, Cl):-

LDH:-

ABG 27.10.2021:-

RFT 27.10.2021:-

Hemogram 27.10.2021:-

Hemogram 26.10.2021:-

TREATMENT:-

 Patient vitals:-

CLINICAL FINDINGS:-

A 38/M came to the OPD 5 days ago with right lower limb swelling and pain after a snake bite. He initially went to a government hospital and was treated with ASV for 3 days. He was then referred to our hospital.

  He was found to have edema in the right lower limb. Also, he had diminished vision. At present, he has cough and shortness of breath since 1 day, burning micturition since today morning and pain in right lower limb.

Personal history: Diet is mixed, appetite is reduced, sleep is adequate and micturition is reduced. Bowel movements are regular. Patient is a regular alcoholic and chews tobacco a lot.

Examination: Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis, clubbing. Oedema seen in right lower limb

Vitals: temperature - afebrile

Pulse rate: 99bpm

Respiratory rate: 18 breaths per minute

BP: 110/80 mmHg

SPO2: 98%

GRBS: 151mg

CVS: S1, S2 heard, no murmurs.

Respiratory system: Position of trachea is central, vesicular breathing sounds heard.

Abdomen: shape of abdomen is scaphoid, bowel sounds heard

CNS: Patient is conscious, coherent and cooperative

Investigations:-

Diagnosis:-

AKI secondary to snake bite (nephrotoxic)

?ATN with right lower limb cellulitis