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

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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