CKD ON MHD WITH UREAMIC ENCEPHALOPATHY

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A 58 year old male 

clo- drowsiness since 1 day

Decreased sensorium since 1 day

Patient was apparently asymptommatic 3 years back

Then patient complained of polyuria, polydypsia, and was diagnosed as Diabetes Mellitus type -2

3 years back had history of 

pedal odema and shortness of breath diagnosed as renal failure but was not on any medication

1 year back patient had h/o hemiplegia patient was on antiplatelet drugs and physiotherapy

20 days back patient had history of pedal edema, shortnes of breath and was initiated on dialysis in view of metabolic acidosis

Last session : 22/11/2021

HISTORY OF PAST  ILLNESS:

DM TYPE 2 SINCE 5 YEARS

CKD SINCE 3 YEARS

 Left CVA 1 year back

Stopped taking alcohol since ?

Vitals at the time of admission

Temp: Afebrile

PR: 88 bpm

RR: 22 cpm

BP: 140/90 mm hg

Spo2: 99% at room air

Grbs: 66 mg) dl after one pint 25%D 101mg /dl

CVS: S1S2+

RS: BAE+, NVBS+

P/A: SOFT, NON TENDER

CNS:

GCS: E4 V3 M6

Patient is irritable, drowsy

Speech- incoherent, following simple commands

Pupils:  Anisocoria +

Sensory, motor system cannot be elicited

Reflexes:

Right- Biceps ++

           Triceps ++

           Supinator -

           Knee -

           Ankle -

           Plantar- flexor

Left 

           Biceps +

           Triceps +

           Supinator -

           Knee -

           Ankle -

           Plantar: mute

Diagnosis:

CKD ON MHD WITH HYPERTENSION AND DIABETES MELLITUS WITH LEFT CVA WITH? URAEMIC ENCEPHALOPTHY

Treatment:

FLUID AND SALT RESTRICTION

 INJ LASIX 40MG IV/BD

TAB CINOD 10MG PO/BD
TAB NODOSIS 500MG PO/BD
TAB SHELCAL CT PO/OD
INJ ZOFER 4MG IV/SOS
INJ. ERYTHROPOIETIN 4000IU S/C ONCE WEEKLY
INJ IRON SUCROSE 1AMP IN 100ML NS IV/ WEEKLY ONCE/ DURING DIALYSIS
TAB PAN 40MG PO/OD
GRBS MONITORONG 6TH HOURLY
INJ. HAI S/C ACC TO SLIDING SCALE