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UREMIC ENCEPHALOPATHY with AKI on CKD

IMMANI AASRITHA, GM
3rd sem, roll num:49
August 05, 2021
User the guidence of Dr. Meghana (intern)
UREMIC ENCEPHALOPATHY with AKI on CKD

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.
ON GOING CASE

CASE SCENARIO:
A 75 year old male patient came to casuality in unresponsive state since 1 hour.
Patient was having fever since 10 days .

HISTORY OF PRESENT ILLNESS:
The 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.
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
 
HISTORY OF PAST ILLNESS:
No h/o diabetes ,HTN,Asthama ,TB and epilepsy 

TREATMENT HISTORY
???????

PERSONAL HISTORY:
Appetite -decreased since two months 
Sleep -excess
Bowel and bladder movements -normal nd regular 
Addictions -none 

FAMILY HISTORY
Not significant

GENERAL EXAMINATION:
No icterus, clubbing, lymphadenopathy, edema, pallor, cyanosis,kolionychia

SYSTEMIC EXAMINATION:
Glasgow sacale: E1,V1M1
BP-140 systolic 
PR-42/min,regularly,irregular 
RR-BLAE present

CVS :
 S1S2 HEARD 
no thrills no murmurs

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

INVESTIGATION

PROVISIONAL DIAGNOSIS- Uremic encephalopathy with AKI on CKD

TREATMENT
????????


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