Case history -1

 Date of admission: 04-08-2021

 A 45 year old female presented to OPD with chief complains of snake bite 7days back . 

HISTORY OF PRESENT ILLNESS:

Patient was  apparently asymptomatic 5 days back then around 7:30 pm on Wednesday presented with snake bite ( viper) and taken to local hospital after an hour  Anti snake venom  was given  she was fine for one day and there was swelling in right lower limb and later the local hospital was advised her ointment and swelling was subsided.

Patient was presented with of vomiting , epilepsy, bilious and with presence of food particles not blood .

Patient was presented with abdominal pain 4 days and it was on the peri umbilical region and squeezing type.

Patient had headache 

No h/o of pedal edema ,  facial palsy .

No h/o of burning micturation

No h/o of photophobia , diplopia, lacrimation, phonophobia .

No h/o of chest pain, palpation, syncopal attack 

No h/o of SOB ( shortness of breath) , PND ( paroxsymal nocturnal dyspnea) , asthma.

HISTORY OF PAST ILLNESS:

There is no history of diabetes, hypertension, epilepsy , asthma .

FAMILY HISTORY:

No similar complaints are present in the family.

PERSONAL HISTORY:

Patient has no loss of appetite.

Mixed - diet.

Appetite - normal.

Sleep- adequate.

Bowel habits- normal.

Micturation- decreased .

She is married and have 4 children.

Menstruation- normal menstrual cycle with normal flow.

Menarche-11yrs .

GENERAL- PHYSICAL EXAMINATION:

Patient is coherent , cooperative and viewed in well lit room. 

pallor, no clubbing , no anemia , no cyanosis , no generalised lymphadenopathy 

No biphedal edema .

Vitals : 

Temperature : afebrile .

BP : 150/ 90 mm hg 

RR: 24/ min 

SpO2 at room crisis: 98

GRBS: 138mg/dl.

SYSTEMIC EXAMINATION:

CVS:

Chest wall is bilaterally systemically. No pre cordial bulge. No visible pulspations, engorged veins , scars and sinuses.

Auscultation : S1 and S2 are heard .

Respiratory system: position of trachea is central. Bilateral air entry is postive. Normal vesicular breath is heard and no added sounds .

Per abdomen: 

Abdomen is distended, soft and non tender. Bowel sounds are heard . No palpable mass or free fluid.

CNS: 

Patient is conscious and speech is normal .No signs of mengieal irritation . Motor and sensory system is normal . Reflexes is normal .cranial nerves are intact .

INVESTIGATION:

  

PROVISIONAL DIAGNOSIS:

Acute kidney injury secondary to acute tubular necrosis secondary to snake bite and thrombocytopenia.

TREATMENT: 

1) Foley's catherterization for output monitoring.

2) oral fluids _ 3L/ day.

3) inj. Lasix 40 mg IV / BD.

4) Strict I/O monitoring.

5) Review SOS.

Mechanism of viper to cause tubular blockage :

There are alot of abnormalities thta cause acute local failure of kidney . Those are bleeding , hypotension, circulatory collapse , intravenous haemolysis , DIC.

HYPERSENSITIVITY to venous protein or antivenomes protein causes acute renal failure.

Type of snake and there complications and clinical features :

Cobras, sea snakes, mambas - neurotoxic- hypotension, shock , other organ dysfunction ( renal impairment).

Vipers - heamotoxic - progressive swelling, hypovolemic shock, developing of blisters and brusing.

Cobra (Naja ) - cytotoxic - extensive tissue injuries and nervous injury .

Snake bite that cause systemic complications: 

Venom alters the capillary membrane preamibility causing extravasation of electrolytes, albumin and red blood cells through the vessel wall into the envenomated site. This process may occur in lungs, myocardium , kidney, peritoneum, rarely CNS.

Techniques:

First aid 

Administration of antivenom 

Mechanical ventilation may be necessary