C/o alternated sensorium since 2 days pedal edema since 20 days

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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