UREMIC ENCEPHALOPATHY WITH AKI AND CKD

G. Bhanuja
Roll no. 46
3rd sem
                ON GOING CASE :
This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.
I have 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 a diagnosis and treatment plan.

CASE scenario:

A 75years old male patient came to the causality in  UNRESPONSIVE STATE SINCE ONE HOUR AND WAS HAVING FEVER SINCE 10 DAYS

HISTORY OF PRESENT ILLNESS

Patient was apparently 
 asymptomatic 10days back then he had insidious onset of fever ,low grade intermittent ,releived with medication,not associated with any chills and Rigors.
Yesterday morning he woke up,done his routine works and was normal till evening ,went to sleep and they tried to wake him up,as the patient was unresponsive they brought him to our hospital.

4 months back patient wide was demised ,from then he was not interacting actively with his family members and having excessive sleep 
Patient attendees are saying that patient had h/o wt loss 
Patient had h/o left sided scrotal swelling since 6 years
 
PAST ILLNESS :

No h/o diabetes ,HTN,Asthama ,TB and epilepsy 
PERSONAL HISTORY :

Appetite -decreased since two months 
Sleep -excess
Bowel and bladder movements -normal nd regular 
Addictions -none 
 
FAMILY HISTORY:
not significant 

ON EXAMINATION:
GENERAL EXAMINATION: 
No pallor 
No cyanosis
No clubbing 
No lymphadneopathy
Noicterus 
No edema 
No kolionychia 

SYSTEMIC EXAMINATION:

E1,V1,M1
BP-140 systolic 
PR-42/min,regularly,irregular 
RR-BLAE present

CVS :
 S1S2 HEARD 
no thrills no murmurs

Per abdomen:
Non distended
Diffuse tenderness absent 
Guarding and rigidity absent

CNS-
                  Right Left 
Tone UL. Hyper Hypo 
           LL. Hypo Hypo 

Power UL - -
             LL - -

Reflexes-
            B- ++ ++
            T- ++ ++
            S ++ ++
            K- + -
            A- - -
            P- extensor extensor

INVESTIGATIONS :

DIAGNOSIS:
? UREMIC ENCEPHALOPATHY with AKI and CKD 

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