Uremic encephalopathy

Hello everyone ! Iam an intern in the medicine department.one of the important terms of getting the internship completion is to complete my log book with my daily log with what i learn during the course of my duties.
Case presentation
-Patient came with the complaint of generalised tonic clonic type of seizure(1 episode) 
-Complaint of low back ache
Complaint of slurring of speech

HOPI
-Patient was apparently asymptomatic 1 day back then she developed generalised tonic clonic seizure? in the evening( detailed history was not given)
-Complaints of low back ache
-Complaints of slurring of speech
-Not associated with fever,cough,cold,pedal edema,pain abdomen
-Drug history details,last LMP details,any poison intake history not availabe.

Past history
History of fever and cough before 1 week which got subsided
History of abortion 5 years back

Drug history
Not allergic to any known drugs

Family history
No similar complaints in the family

Personal history: 
She was married 10 yrs ago.she had an abortion before 5 yrs .she got  seperated from her husband.
She married another person before 4 yrs .since then she was living with him and did not visit her parents. She developed seizures during her travel in bus while she was coming to visit her parents.
Diet: mixed
Appetite: normal
Sleep: adequate 
Bowel and bladder movements: regular
No addictions

General examination
Patient is conscious and coherent but after 2 hrs she had altered sensorium.
Well built and well nourished
 
Vitals
BP:140/90mm HG measured on right arm in supine position.
PR: 102 bpm
Temperature:99.6 degree F
RR:16 cpm
Spo2 :98%
There is pallor
No icterus,cyanosis,clubbing,lymphadenopathy,
Edema

CVS Examination:
S1,S2 heard
No murmurs

Respiratory Examination:
No dyspnea ,wheeze 
Vesicular breath sounds
No added breath sounds

Per abdomen:
No tenderness,local rise of temperature
Abdomen: scaphoid
Hernial orifices: free

CNS examination:
Tone of upper limb and lower limb : notmal
Power: cannot be elicited
But by looking her she is moving her limbs 
Most likely power is 3/ 5 for all limbs
Deep tendon reflexes : absent
Plantar reflex : right and left leg extensor response


Investigations :Hemogram,RFT,LFT,ABG,Coombs test,spot urine protein,creatinine,PT,APTT,BUN,CT BRAIN,USG Abdomen,BT,CT,BUN

Significant details
Hemoglobin 3
Serum creatinine 12.1
BUN 60.7
ALP 1004
USG findings : right kidney:Grade 3 RPD Size:6.5X3.2 cm
Left kidney:Grade 2 RPD Size:8.8X 4.0cm
Day 1
1 unit blood transfusion.Hb: 4.4
 one session of hemodialysis was done.
1 unit of blood transfusion during dialysis.

Day 2:
GCS:10 /15 E4 V2 M4
Deep tendon reflexes : absent ,plantar reflex : positive both right and left limb
Bp:120/80mm Hg
Pulse rate:98 per minute
 1 session of hemodialysis was done .
1 unit of blood transfusion during dialysis 
High grade fever,persistent spikes are present.High grade fever 101.4 degreeF at 10: amand 104 degree F at 6 pm
Urea:94 
Creatinine:7.3

Day 3
GCS:11/15 E4 V3 M4
Deep tendon reflexes : absent
Plantar reflex : mute for both limbs
Tenderness over left knee.
MRI brain was done
Temperature:100 degree F
MRI Report
Day 4
GCS :12 / 15
Deep tendon reflexes: absent
Plantar reflex:mute for both limbs
1 session of hemodialysis done.

Day 5:
GCS:13/15 E4 V4 M5
Deep tendon reflexes : absent
Day 6:
GCS:15/15 E4 V5 M6
Patient is conscious and coherent.
Deep tendon reflexes : absent
1 session of hemodialysis was done.1 unit blood transfusion was done.
Patient complaints of pain over left knee region.
Xray of left knee 
Day 7:
GCS : 15/15
Treatment given:
- Head end elevation
-Inj Levipil 500 mg IV /BD
- Inj Monocef 2 gm IV / BD X 7 days
-Inj pantop 40 mg IV /OD
Salt and fluid restriction
-RT feeds 100 ml milk + protein powder every 2 hrly for 3 days .RT was removed on 4th day, soft feeds were given from fourth day.
-Air bed
-From 3rd day inj falcigo  120 mg was started.
Dose 0 given at 7:00 pm on 3 rd day
Dose 1 given at 7:00 am on 4th day
Dose 2 given at 7:00 am on 5 th day
Dose 3 given at 7:00 am on 6 th day
Doxycycline was started from 4 th day.
Dose 1 given on 4 th day 
Dose 2 given on 5 th day
Dose 3 given on 6 th day

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