Skip to main content

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
????????


Comments

Popular posts from this blog

gm case

GM e log July 08, 2022 This is an 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 patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's 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 on the comment box is welcome. IMMANI AASRITHA Roll no.49 5th semester July 10, 2022 GENERAL MEDICINE. CASE REPORT: A 49year old female patient resident of west bengal and farmer by occupation came to the OPD with chief complaints of pain in multiple joints and headache. HISTORY OF PRESENT ILLNESS: The patient was apparently asymptomatic 10 years back. C/o pain in shoulder joint, ankle joint, mcp and mtp joints,pip joint, wrist, elbow and knee joints since 10 years. (More in the ...

49 Aasritha, GM, 52 year male with LL(R) swelling

IMMANI AASRITHA 3rd sem, roll num:49 under the guidance of Dr. Rishik (Intern) 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 52yr old patient came to the ward on 29 June 2021 with chief complaints of right lower limb swelling, intermittent fever (alive and well), shortness of breath since 3days, and burning micturition for 15 days. HISTORY OF PRESENTING ILLNESS The patient was asymptomatic 5days ago, after which he developed right lower limb swelling up to the knee. No H/O trauma, thorn prick, nausea, vomiting c/o a small wound, watery discharge since 2 days Fever- 5days intermittent, low grade, a/w chill A light rise in temp so...

A 60F with megaloblastic anemia

  Nov29, 2023 This is an 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 patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's 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 on the comment box is welcome. IMMANI AASRITHA Roll no.49 8th semester Nov 28, 2023 GENERAL MEDICINE DOA - 27/11/2023 CHIEF COMPLAINTS : Fever since 1 week Palpitations since 1 week  Generalised weakness since 4 days  Blood in stools since 3 days  Chest pain and tightness since 4 days HISTORY OF PRESENTING ILLNESS  The patient was apparently asymptomatic 1 week ago and then she developed fever which is sudden in onset, high grade, associated with chills and rigors, relieved tempor...