65/M WITH RENAL AKI SECONDARY TO UTI

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan.

CASE SCENARIO

A 65 yr old male came to the opd with C/C of 

Generalized weakness and not Able to walk since 2 weeks

Fever since 1 week

Loss of appetite and nausea since 1 week

B/L pedal oedema since 1 week

Decreased urine output since 1 week

Burning micturition since 1 week

Drowsiness since 1 day

HISTORY OF PRESENT ILLNESS

       Patient was apparently alright 1 week back then he had 

Insidious onset of fever, low grade, intermittent, not associated with chills and rigors. Relived on taking medication.

Pedal edema - insidious in onset, gradually progressive from foot to knee and is pitting type.

No PND and orthopnea

Fever is associated with loss of appetite, nausea, generalised weakness and unable to walk

There is decreased in the urine output and burning micturition since 1 week

From 1day the patient is drowsy and excessively sleepy

PAST HISTORY

      Not a known case of diabetes, HTN, CAD, asthma and TB

PERSONAL HISTORY

Occupation - used to work as labour in crop fields.

Appetite - Decreased

Diet - mixed

Bowel movements - regular 

Micturution - decreased

Alcohol - Regular - takes 180ml/day since 3years

FAMILY HISTORY

       No significant family history

GENERAL EXAMINATION

No pallor 

No icterus 

No cyanosis and clubbing

No lymphadenopathy 

Edema - pedal and pitting type

Vitals

Temperature - 99.4°F

PR - 103bpm

RR - 28cpm

BP - 130/70mm Hg

SpO2 - 95%

GRBS - 86 mg%

SYSTEMIC EXAMINATION

CVS:S1 S2 HEARD, NO MURMURS.

RS: NVBS heard, BAE +, TRACHEA CENTRAL.

P/A : SOFT, NON TENDER, NON DISTENDED.

CNS: CONSCIOUS, NO SIGNS OF MENINGEAL IRRITATION.

REFLEXES.

                                      RT. LT.

                   BICEPS.       + +

                   TRICEPS.      + +

                   SUPINATOR. + +

                   KNEE              + +

                   ANKL            + +

                   PLANTAR: FLEXOR.

PROVISIONAL DIAGNOSIS

    UTI WITH AKI WITH HYPONATREMIA

INVESTIGATIONS 

1) ECG 

2) Ultrasound

3) Chest X - ray

4) ABG

5) RFT

6) Serology 

7) Haemogram

8) 2D ECHO

TREATMENT

• FOSFOMYCIN sachet - 3mg in 1glass of water/ stat

• Tab DOLO 650mg PO/ TID

• Tab NODOSIS PO/BD

• Strict I/O charting

• Condome Catheterization

• Inj LASIX 40mg IV/BD if SBP > or = 110mmHg

• IVF 20NS @75ml/hr

• Temperature charting 4th hourly

• GRBS charting 8th hourly

• BP / PR / RR / Spo2 charting 2nd hourly

DAY 2 

 SUBJECTIVE:

Altere sensorium

OBJECTIVE

Temperature-97 F

Bp-120/60 mmhg

PR- 90bpm

RR -11 cpm

GRBS - 90 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

1) Central line placed with consent taken

    Complication: Hemothorax

    --- X ray

     

ICD placed 

Xray post icd 

 Day3

SUBJECTIVE:

Fever spike

Stools not passed

Drowsy but arousable

OBJECTIVE

Temperature-101 F

Bp-130/80 mmhg

PR- 90bpm

RR -11 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Dialysis done(along with Blood Transfusion)(1 unit)

Urine culture on mc conkey agar 

       1) lactose fermenting colonies formed(pink)

       2) Indole(+ve), citrate(-ve), urease(+ve), 

       3) Triple sugar iron -- A/A WITH GAS

       4) Gram Stain -- Gram -ve bacilli

F/S/O:- E-coli

Day 4

SUBJECTIVE:

PAIN AT DRAIN SITE

OBJECTIVE

Temperature-101 F

Bp-150/80 mmhg

PR- 86bpm

RR -16 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Syp. LACTULOSE 10ml/RT/HS

13. 2nd dialysis done (Along with Blood Transfusion)(1 unit)

Day 5

SUBJECTIVE:

PAIN AT DRAIN SITE

OBJECTIVE

Temperature-101 F

Bp-150/80 mmhg

PR- 86bpm

RR -16 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Syp. LACTULOSE 10ml/RT/HS

Day 6

SUBJECTIVE:

PAIN AT DRAIN SITE

OBJECTIVE

Temperature-101 F

Bp-150/80 mmhg

PR- 86bpm

RR -16 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Syp. LACTULOSE 10ml/RT/HS

13.3rd dialysis done (along with 1 unit of blood transfusion)

Day 7-

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Subjective : 

 Pt complaints of burning micturition 

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1) ORAL FEEDS 

2. inj PIPTAZ 2.25gm /iv /tid 

3. Inj METROGYL 100ml / iv/tid 

4. Inj PAN 40mg /iv / od 

5. TAB LASIX 40mg /po/ od 

6. Tab NODOSIS 500 mg /po /od 

7. Tab DOLO 650mg /po/sos 

8. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

9. SYP LACTULISE 10ml /po/ HIS

Day 8

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

 

Foley's removed and planned for ICD removal

Day 9

SOAP NOTES 

 A 65 yr old man with AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid. BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

Day 10

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

Day 11

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

Day 12

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

CASE OF A 65 YR OLD MALE WITH CKD : LONG CASE GM (1601006087)

 

CASE OF A 65 YR OLD MALE WITH CKD : LONG CASE GM FINALS

1601006087

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 is the case i have been given :

A 65 year old male who was a farmer came to the OPD with

 CHIEF COMPLAINTS OF :

1. Decreased urine out since 4 months

2. Bilateral pedal edema since 4 months and 

3. Abdominal distension since 4 months

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 4 months back then developed decreased urine output , which is insidious in onset with decreased frequency and later facial puffiness followed by bilateral pedal edema , pitting type, gradually progressed to involve abdomen with abdominal distension, no aggregating and relieving factors. 

There is history of pruritus and pigmentation of both the lower limbs

PAST HISTORY : 

He was k/c/o HTN since 5 yrs and was on medications

No h/o suggesting DM, CAD, CVA, TB, asthma, epilepsy

10 yrs back patient had a road Traffic accident for which surgery(? Intramedullary nail insitu) was done for ?hip fracture In nalgonda govt hospital. He had taken NSAIDS for 1 year then.

1 year back patient gives history of taking NSAIDS 3 tabs per day daily for bilateral knee and back pain given by RMP. He took it daily for 1 year

Patient also gives a h/o bilateral Tympanic membrane perforation 6 yrs back (following an infection).

He gives a history of cataract surgery for right eye 10years ago

FAMILY HISTORY : 

No k/c/o HTN,DM,TB, asthama,CAD, epilepsy and CKD

PERSONAL HISTORY :

Mixed diet

Appetwite is reduced

Sleep is adequate

Bowel regular

Oliguria since 4 months

Addictions :  h/o beedi smoking 4-5 years ,stopped 1 year back

GENERAL EXAMINATION :

• Patient is conscious, coherent & cooperative 

• Thin built and malnourished

GENERAL SIGNS :

• PALLOR present

• No Icterus, cyanosis,clubbing koilonychia and Lymphadenopathy 

PEDAL EDEMA + , which is pitting type

VITALS :

• Temp: 98.5 F,

• RR : 18 cycles/min,

• BP : 100/70mmHg,

• PR : 80/min, regular rythm, normal volume,no radio-radial or radio-femoral delay, Condition of the vessel wall is normal

• SpO2: 97% on RA

SYSTEMIC EXAMINATION :

• CVS: s1 s2 +

 no murmurs

• RS:

Bilateral air entry present

Normal vesicular breath sounds, No added sounds

• CNS:

All higher motor functions are normal

Except 8th nerve (Bilateral sensory neural hearing loss present). All other Cranial nerves are intact

Sensory system normal

Motor system normal

Cerebellar signs normal

No meningeal signs

• Per abdomen :

Soft

Non tender

No organomegaly

Bowel sounds heard

INVESTIGATIONS :

Complete blood picture

Complete urine examination

Serum iron

Renal function tests

Liver function tests

Blood grouping & Rh typing

HIV

HbsAg

Anti HCV Antibodies

SARS COVID

USG

ECG 

PROVISONAL DIAGNOSIS:

CKD stage II, secondary to NSAID abuse

TREATMENT GIVEN :

The patient was on hemodialysis along with drugs

Hemodialysis chart

Fluid & salt retention (< 1 litre/day and <2gm/day )

Tab. Nicardia 10 mg TID

Tab. Lasix 40 md BD

Tab. Nododis 500 mg BD

Tab. Shelcol OD

CAP - alpha -D3 OD

Sodium bicarbonate

Injection iron sucrose 100 mg BD

Injection Monocef 1g BD

Injection erythropoietin 4000 iu/ one weekly

CASE OF A 40 YEAR FEMALE WITH PEDAL EDEMA : SHORT CASE (1601006087)

 

CASE OF A 40 YEAR FEMALE WITH PEDAL EDEMA : SHORT CASE

1601006087

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 IS THE CASE I HAVE BEEN GIVEN :

A 40 year old female patient, works at a construction site came to the opd with

CHIEF COMPLAINTS OF :

1. Chest pain since 5 days

2. Shortness of breath since 5 days

HISTORY OF PRESENT ILLNESS :

The patient was apparently asymptomatic 5 days ago, the she developed chest pain, non radiating &  increased on taking deep inspiration.

Shortness of breath on & off

No h/o orthopnea, PND, fever, Cough

PAST HISTORY :  Not a k/c/o DM, HTN, CAD, Asthama, epilepsy and Tb

PERSONAL HISTORY :

Mixed diet

Appetite normal

Sleep is adequate

Bowel and bladder movements regular

No addictions

FAMILY HISTORY : Not significant

GENERAL EXAMINATION :

• She is conscious,coherent and cooperative

• Moderately built & moderately nourished

• No Pallor, icterus,clubbing,cyanosis,koilonychia and lymphedeopathy

BILATERAL PEDAL EDEMA present, pitting type 

• JVP is raised - 5cm

VITALS :

 •Afebrile

• PR : 102 bpm, regular rythm, normal volume, no radio radial & radio femoral delay, condition of the arterial wall is normal.

• RR : 18 cpm

• B.P : 110/80 mm hg

SYSTEMIC EXAMINATION :

• CVS : S1, S2 + , No added murmurs

• RS : NVBS, bilateral air entry present, no added sounds

• CNS : 

All higher motor functions are normal

Cranial nerves intact

Sensory system normal

Motor system normal

Cerebellar signs normal

No meningeal signs

• P/A : Soft, non tender, no organomegaly, bowel sounds heard

INVESTIGATIONS :

Complete blood picture :

ECG :

COLOUR DOPPLER 2D ECHO

TREATMENT GIVEN :

Tab. Nexpro 40 mg OD

Syrup sucralfate 10 mg TID

Provisional Diagnosis: early signs of right heart failure

CASE OF A 60 YEAR OLD MALE WITH CKD

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April 23, 2021

CASE OF A 60 YEAR OLD MALE WITH CKD

This is the case i have been given :

A 65 year old male who was a farmer came to the OPD with

 CHIEF COMPLAINTS OF :

1. Decreased urine out since 4 months

2. Bilateral pedal edema since 4 months and 

3. Abdominal distension since 4 months

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 4 months back then developed decreased urine output , which is insidious in onset with decreased frequency and later facial puffiness followed by bilateral pedal edema , pitting type, gradually progressed to involve abdomen with abdominal distension, no aggregating and relieving factors. 

There is history of pruritus and pigmentation of both the lower limbs

PAST HISTORY : 

He was k/c/o HTN since 5 yrs and was on medications

No h/o suggesting DM, CAD, CVA, TB, asthma, epilepsy

10 yrs back patient had a road Traffic accident for which surgery(? Intramedullary nail insitu) was done for ?hip fracture In nalgonda govt hospital. He had taken NSAIDS for 1 year then.

4yrs back he developed perforation in tympanum and later progressed to hearing loss

1 year back patient gives history of taking NSAIDS 3 tabs per day daily for bilateral knee and back pain given by RMP. He took it daily for 1 year

He gives a history of cataract surgery for right eye 10years ago

FAMILY HISTORY : 

No k/c/o HTN,DM,TB, asthama,CAD, epilepsy and CKD

PERSONAL HISTORY :

Mixed diet

Appetite is reduced

Sleep is adequate

Bowel regular

Oliguria since 4 months

Addictions : h/o beedi smoking 4-5 years ,stopped 1 year back

GENERAL EXAMINATION :

• Patient is conscious, coherent & cooperative 

• Thin built and malnourished

GENERAL SIGNS :

• PALLOR present

• No Icterus, cyanosis,clubbing koilonychia and Lymphadenopathy 

PEDAL EDEMA + , which is pitting type

VITALS :

• Temp: 98.5 F,

• RR : 18 cycles/min,

• BP : 100/70mmHg,

• PR : 80/min, regular rythm, normal volume,no radio-radial or radio-femoral delay, Condition of the vessel wall is normal

• SpO2: 97% on RA

SYSTEMIC EXAMINATION :

• CVS: s1 s2 +

 no murmurs

• RS:

Bilateral air entry present

Normal vesicular breath sounds, No added sounds

• CNS:

1)Intellectual functions

 -patient is conscious,oriented to time ,place and person

-memory-immediate,recent and remote memory present

-appearence-well kept

-speech-normal 

2)cranial nerves

Olfactory-smell present on both sides

Optic-visual acuity -6/6

    Visual field,colour vision,reflexes -normal 

3,4,6 cranial nerves-ocular movements -present

         Nystagmus,pros is,Diplopoda-absent

       Pupils are normal

Trigeminal -motor and sensory functions normal on both sides

 Facial nerve

-No deviation of mouth 

-frowning present

-absent nasolabial folds on left side

-blowing and whistling absent

Taste sensation on anterior 2/3rd of tongue present

Corneal reflexpresent on both sides

Vestibulocochlear nerve-rinnes Weber,schwabach test Negative on both sides

Vagus and glossopharyngeal -uvula midline

Spinal accessory-shrugging of shoulders present

Hypoglossal-no deviation of tongue

3)Motor system

A)attitude and position-Normal

B)bulk-no wasting

C)tone-Rt Lt

UL N N

LL N N

D)power-

UL Rt Lt

      -5/5 -5/5

LL -5/5 4/5

4)Reflexes

Superficial Rt Lt

  Corneal +2 +2

 Conjunctival +2 +2

Abdominal +2 +2        

Deep Rt Lt

Biceps +2 +3

Triceps +2 +2

Supinator +2 +2

Knee +2 +2

Ankle 0 0

5)Sensory system  

Superficial -fine touch,temperature,pain -present

Deep-position,vibration,crude touch,stereognosis,2point discrimination- present 

6)Cerebellum 

Speech,nystagmus,ataxia,tremors,released reflexes absent

7)Coordination and gait

Finger nose test ,finger finger test,heel knee test-present

Gait -dragging type

 Romberg test -negative

8)signs of meningeal irritation

Nuchal rigidity,kernigs and brudzinski’s sign - absent

• Per abdomen :

Soft

Non tender

No organomegaly

Bowel sounds heard

INVESTIGATIONS :

Complete blood picture

Complete urine examination

TREATMENT GIVEN :

The patient was on hemodialysis along with drugs

Hemodialysis chart

Fluid & salt retention (< 1 litre/day and <2gm/day )

Tab. Nicardia 10 mg TID

Tab. Lasix 40 md BD

Tab. Nododis 500 mg BD

Tab. Shelcol OD

CAP - alpha -D3 OD

Sodium bicarbonate

Injection iron sucrose 100 mg BD

Injection Monocef 1g BD

Injection erythropoietin 4000 iu/ one weekly