c/O altered Sensorium and pedal edema

Unit 5 admission 
Interns-
Dr. Shriya Reddy
Dr. Anjali
Dr. Konda Soumya 
Dr. Sreedevi
Dr. Mourya 
Dr. Shashikala pgy1
Dr. Shailesh Patil pgy1
Dr. Zain alam pgy2
Dr. Natasha pgy3
Dr. Praveen Naik Associate professor
Dr. Rakesh biswas HOD
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.
Complain of altered sensorium since two days 
Pedal edema since 20 days 
Decreased urine output since a week 
Pt was asymptomatic 20 days ago then developed pitting edema of left leg till knee , he also developed blebs 
Urine output is decreased and associated with burning micturition 
Had fever which is intermittent relieved on medication high grade ass with chills n rigors
Later blebs coalesed with pus associated with skin excoriation and skin redness
Not a k/c/o htn dm tb epilepsy asthma 
K/c/o ckd on conservative medication since 5 yrs 
Vitals bp -130/70 mmhg 
Pr-72 bpm 
Rr-17 cpm 
Spo2-98 
Cvs- s1s2 heard no murmurs 
Rs- nvbs
General examination:no pallor,
Icterus ,cyanosis ,clubbing lymphademopathy,Edema.


Cvs apex beat in 5th ICS medial to midclavicular line
pan systolic murmur+

Rs bae + nvbs hears

P/a soft ,nontender,bowels sound heard,

Cns  
HMF- patient conscious

 Lobar function tests
1.Frontal:social behaviour:normal
                 language:normal
                micturation:normal
2.parietal dominant: language, calculations normal,
               ideational apraxia:present
              right left orientation:present
              finger agnosia :absent
             simple and complex calculations normal
             
3.parietal non dominant
              constructional skills:?
4.Temporal:
            memory and language:normal
5.occipital
          visual memory:normal
          prosopagnosia:absent


speech- normal

MMSE-
28/30(No cognitive impairment)

cranial nerves-1st normal

2nd Counting fingers at 6mts both eyes normal
                                             rt         lf
3rd,4th,6th
                     pupil size.      N         N
                     DLR/CLR.       N.        N
NO pstosis, nystagmus.

5th sensory normal
motor normal
reflex corneal normal,conjuctival present

7th motor nasolabial fold normal
no deviation of mouth
reflex corenal and conjuctival normal
secretomotor moistness of eye and tongue normal,buccal mucosa normal

8 the nerve:Rinnes and Weber's  not elicited

9and 10 th nerve: uvula centrally placed

11 th nerve: trapezieus normal sternocleidomastoid normal

12 th nerve: tongue tone normal, no wasting, no fibrillations,no deviation of tongue

MOTOR SYSTEM 
                         Right.         Left
Bulk:               normal.      Normal
Tone: ul.        Normal.   Normal
           LL.       normal      normal
Power      UL  prox4/5.         4/5
                       distal 4/5.       4/5
                  LL.prox 4/5.         4/5
                       distal 4/5.      4/5
Reflexes.  
   Superficial reflexes
                       Right.           Left
Corneal.        P                   P
Conjunctival P.                  P
Abdominal.   P.                  P
Plantar           flexion     flexion
    Deep tendon reflexes 
                     Right.             Left
Biceps.       +1.                         +1
Triceps.     +1.                       +1
Supinator.    -                     -
Knee             +1-                    +1
Ankle.          Cannot be elicited -
Involuntary movements - absent 
 
SENSORY SYSTEM 
                                 R.                 L
Pain.                        +.                 +
fine touch.              +.                  +
temp.                       +.                 +
vibration (decreased)
medial malleolus. 9sec.   9sec
patella.                     9sec 9sec
upper limb.               9sec.   9sec     

propriception.         N     N
stereognosis.          N     N


CEREBELLUM
titubation - absent
Nystagmus- bidirectional+(Test of skew negative,head impulse ?present)
Intensional tremors - absent
Pendular knee jerk - absent 
Coordination tests
      dysdiadochokinesia absent
      
Tandem walking

MENINGIAL SIGNS
Neck stiffness - absent
Kernigns sign - negative
Brudzinkis sign - negative
Diagnosis AKI ON CKD SECONDARY TO UROSEPSIS / necrotising fasciitis 
With uremic encephalopathy and anemia with chronic disorder

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