A 70 years old female with history of fall

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A 70 year old female home maker since 10-15years ( farmer by occupation before) ,resident of narammagudem, came to casuality in drowsy state .

HISTORY OF PRESENTING ILLNESS:

patient was apparently asymptomatic 11 years back, then the patient had a history of fall , she went to local hospital and got diagnosed with diabetes millitus and since then she is on OHA medication ( glimiperide M2) .

4 years back she had another history of fall , she went to local hospital and got diagnosed with hypertension, and she developed edema , and also undergone dialysis , she is not on medication for hypertension.

1month back she developed hypoglycaemia secondary to OHA's then resolved later .

8 days back she had another history of fall which lead to fracture of rt femur , and was operated ( open reduction and internal fixation).

after 3 days she developed edema , became drowsy, was not able to open eyes fully and responded to deep pain, was not able to recognise the attenders .

she is having abdominal distension and vomiting since 1 day , 3 episodes of vomiting ,billious, non projectile.

PAST HISTOR: 

known case of diabetes since 11yrs and on medication

known case of hypertension since 4yrs

FAMILY HISTORY:

no significant family history 

SOCIAL HISTORY :

she is the only person in the house who cooks on her self and does her regular activities .

GENERAL EXAMINATION:

patient is drowsy , moderately built and moderately nourished 

Pallor: present 

Icterus: absent

Cyanosis: absent 

Clubbing : absent

Odema of feet: pitting type of edema seen 

Lymphadenopathy: absent 

Vitals on admission :

BP: 170/90 mmHg

PR: 98 bpm

RR: 25cpm

Spo2: 95

Grbs:146

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard 

Respiratory system: bilateral air entery present 

Per abdomen : 

Inspection: rounded, no scars 

palpation: slightly warm, non tender, no organomegaly 

percussion: resonant sound heard on percussion

auscultation: bowel sounds heard 

CNS: patient is drowsy

tone is normal

INVESTIGATIONS:

ON 12/2/2022:

Hb: 5.8

TLC: 11,000

smear: microcytic hypochromic anemia 

RBS: 220

ESR: 140

Blood urea: 143

ON 13/2/2022:

Hb: 6.1

TLC: 11,500

she had a blood transfusion

ON 15/2/2022:

ON 16/2/2022:

Bp: 170/90mmHg

Pr: 98bpm

Rr: 22cpm

Grbs:146mg/dl

INVESTIGATIONS:

ULTRA SOUND ON ADMISSION:

RT LOWER LIMB VENOUS DOPPLER:

CT BRAIN:

USG ABDOMEN:

CT ABDOMEN:

Provisional Diagnosis: 

Uremic encephalopathy with pre renal acute kidney injury ,post operative delirium

PLAN :-

1. INJ. Lasix 40mg IV/BD

2. INJ. HAI SC/TID 

3. INJ. CEFTRIAXON 1g/IV/BD

4. INJ. CLINDAMYCIN 600mg/ IV /TID

5.INJ. CLEXANE 20 mg SC/OD

6. INJ. OPTINEURON 1 AMP in 100 ml NS /IV/OD

7.TAB. Amlong 10mg PO /OD

8.IVF NS UO + 30 ml/hr

DISCUSSION:

UREMIC ENCEPHALOPATHY:

Uremic encephalopathy (UE), a toxic metabolic encephalopathy, is an uncommon complication resulting from endogenous uremic toxins in patients with severe renal failure

It generally occurs in patients with acute kidney injury or severe chronic kidney disease

The pathogenesis of UE is complex and remains unclear, and in which neurotoxic compounds are likely to play an important role. Many factors including uremia, parathyroid hormone, metabolic acidosis, abnormal blood glucose, methylguanidine, aluminum poisoning, abnormal osmotic pressure and insufficient blood supply in the brain are considered as possible causative factors