40 year old patient with hepatic encephalopathy

This is a 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 patients problems through series of inputs from available global 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 centered online learning portfolio and your valuable inputs in 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 .

Chief complaints:

 A 35 year old male ,farmer by occupation came to hospital with chief complaints of pain and swelling in right leg and decreased urine output since 4 days.

HOPI:

Patient was apparently asymptomatic 4 days back.Then he had a snake bite while he was in his farm followed by which he developed swelling in right leg near ankle which is extending till knee joint .

Patient also complains of pain in his right leg initially at his ankle, now is extending till thigh.

Patient also developed drooping of his eyelids following snake bite.

Decreased urine output since 4 days

He was first taken to hospital where they treated him and referred the patient to our hospital for dialysis.

H/O 1 PRBC transfusion with 2 SDP transfusion.

Past history:

Not a known case of DM , HTN , TB ,epilepsy, asthma .

Personal history: 

Appetite- Normal 

Diet - Mixed 

Bowel and bladder - Regular 

Sleep - Adequate 

Addictions - No

General examination: 

Patient is conscious, coherent, cooperative,moderately built and moderately nourished 

Pallor - Present 

Icterus - absent

Cyanosis- absent

Clubbing- absent 

Lymphadenopathy- absent

Edema - till knee joint

Vitals- Temp - 98.5F

            Pulse- 99bpm

            RR- 18cpm

            BP - 110/80mmhg

            Spo2- 98% at RA

            GRBS - 151 mg%

Systemic examination:

CVS - S1 , S2 heard ; no murmurs 

Respiratory system - BAE present, NVBS heard

Abdomen - Soft , non tender

CNS - NAD

Provisional diagnosis:

AKI 2° to snake bite

?ATN with right lower limb cellulitis

Clinical images:

NEclUROTOXIC)

? ATN WITH RT LOWER LIMB CELLULITIS

Ggvhj

Hggh

InveIIIn

vestigations

ECG

USG

22/10/21

24/10/21

Treatment : 

Day 1 

1 session of hemodialysis for 2 hours along with prbc transfusion

Surgery referral and dressings done for rt lower limb cellulitis