snake bite short case 1

A 45 year old female patient farmer by occupation
Resident of Nalgonda 
came to casuality with complaints of vomitings and abdominal pain since 4 days 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6 days back then she was allegedly bitten by snake on her right lateral foot at 7.30 pm while she was cooking, she was taken to local hospital and started on treatment ( 20 min whole blood clotting test was positive started her on Anti snake venom later shifted here ,

C/0 of abdominal pain since 5 days, periumbilical in location, non radiating , pain aggravated with food intake relieved with medications .

C/0 of vomitings since 5
 days 3 to 4 episodes per day, containing non digested food particles non bilious , non projectile in nature, 
 
C/0 swelling of right foot non pitting type insidious in onset progressed upto ankle and releived in 2 days 

C/0 of anorexia , myalgias, fatigue and generalized weakness from 5 days, 

No C/0 of pain at site of bite.

No H/0 of blood oozing from site of bite, epistaxis, hematemesis, Malena.

No H/0 of decreased urine output or cola coloured urine.

No h/o of shortness of breath, chest pain, palpitations, 

No H/o of loose stools , constipation

No h/0 of weakness of limbs , drooling of saliva, ptosis

No h/0 of SOB, PND or orthopnea.

Past history - 
No histoy of hypertension , diabetes, thyroid , epilepsy , tuberculosis and asthma.

Personal history-

Diet - mixed
Sleep- adequate
Appetite - normal
Bowel and bladder - 
Not a alcoholic or smoker

Summary - 
45 year old female patient alleged to snake bite , presententing with Nonoliguric  Acute kidney injury. 

General physical examination- 

Patient was conscious, coherent , well oriented to time place and person

Pallor - present

No Icterus

No clubbing , no cyanosis

No lymphadenopathy

No edema.

Vitals - 

Temp - 98.6 F ( measured in axilla).

PR- 82 beats per min, normal in rhythum, character and volume ,no vessel wall thickening , no radio radial or radio femoral delay.

Bp - 140/ 90 mm hg, measured in right upper arm in supine position.

RR- 16 cpm.

Cvs - S1 , S2 heard, no jvp rise, no murmurs heard , apical impulse- 

Rs - Non vesicular breath sounds heard, equal bilateral air entry , no added sounds.

P/ A - soft , no tenderness elicited, 
  No mass felt, No organomegaly . Bowel sounds heard.

CNS -  
Higher mental functions are normal. 

Tone - normal
power - 5/5 in both limbs, 
All superficial and deep reflexes are normal 
 
Sensory and cerebellar system - intact 

      


INVESTIGATIONS- 

COMPLETE BLOOD PICTURE-  

HB - 8.5 gm/dl.
Platelet count- 63000
WBC count - 9000

RBS- 113mg/dl.

Serum creatinine - 7.4 mg/dl.

Blood urea - 166mg/dl.
BUN - 77.5

Sodium - 124meq/l
Potassium - 3.9meq/l
Chloride - 75meq/l

Spot urine protein creatine ratio - 0.13 .

Spot urine sodium - 229 mmol/ L . 

Complete urine examination- 

Colour - pale yellow

Pus cells - 2-3
Rbcs - nil
Albumin - nil

Bleeding time - 2min 15 secs

Clotting time - 4 min 45 secs.

Total bilirubin - 1.0 mg/ dl
Albumin - 4.5 gm
SGPT - 34 ( 15- 40)
SGOT - 24
ALP - 90 IU/L

ABG - 
       PH - 7.403
       Hco3- 16.7
       Pco2-. 22.1
       Spo2- 97.2 %

Urine protein creatine ratio ,- 0.13

Urinary sodium - 229.


X ray -

        


ECG - 



USG - 

KIDNEY SIZE - Normal, increased echotexture and mild perinephric fluid likely inflammation.

Provisional diagnosis - 

Acute kidney injury , secondary to acute tubular necrosis , due to snake bite . 


Treatment - 
1. 4 sessions of
     haemodialysis
2. Inj zofer 4 mg TID
3. Inj pan 40 mg Od
4. Strict input / output
     charting.

High dose vs low dose anti snake venom 

http://www.ncbi.nlm.nih.gov/pubmed/15633711

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