Chronic renal failure with uremic encephelopathy .? Miliary tuberculosis ? Anemia of chronic disease .

Casualty case 
New admission in nephrology : 

60 year old female resident of nalgonda presented to casualty with complaints of :

Loss of appetite and nausea since 10 days.
Generalised weakness and unable to get up from bed since 3 days.
Decreased urine output since 3 days
Constipation since 3 days.
Altered sensorium since 2 days .
Sob - grade 3 since 1 day.

Pt was a daily wage labourer .She stopped working 1 year ago when her husband passed away and due to generalised weakness ,since then she is staying at home .But does her regular activity at home .
Pt has 2 children . Full term normal vaginal delivery at home. She has no comorbities and has history of NSAID abuse for 5- 6 years for generalised bodyaches. She is chronic chutta smoker since 30 tears (8-10 chuttas per day intially. Since 6 years reduced it to 2-3 chuttas /day ). She is also occasional alcoholic .

6 years ago she had history of fever and genralised edema ,facial puffiness . Loss of appetite , for which she visited a local hospital where they told she has renal failure and was on medications .No decreased output at that point of time.
Her edema subsided after using medications.
She stopped using medications after few days as she was feeling well . 
She has History of dry cough and sob on exertion since 6 years.
Her husband has History of chronic cough- ?pulmonary kochs and expired last year at home .
After her husband expired pt began smoking again.
-8 months ago she again complained of facial puffiness , but no pedal edema . Low grade fever , burning micturition .
She went to local hosp and edema subsided with medications.
Since 3 months patient complained of intermittent low grade fever , loss of appetite.
Cough since 3 months , associated with scanty sputum ,white color .
Generalised weakness and body aches .
No history of weight loss as per attenders.
Pt went to local hospital where they told she has pneumonia and used medications. But her symptoms dint subside.
Attenders also gave history she was tested for tuberculosis but it was negative.( Previous Reports/prescriptions not available) .
She was using intermittently dytor plus tablets.
Since 3 days , she has generalised weakness and decreased urine output and constipation.
Altered sensorium and irritable and irrelevant talk since 2 days.
Sob - grade 3 since 1 day.

O/e : Pt altered sensorium , irritable .
Not oriented to Time/place and person.
Bp- 90/60 mmhg
PR- 115 bpm ,regular , normal volume .
Rr- 37/min ; spo2- 97% on ra.
Grbs -152 mg/dl.
Urine output -30 ml ( over 6-7 hrs ).
Pallor present.
No pedal edema . No raised jvp and no facial puffiness.
 No icterus , cyanosis , clubbing.
- Swelling noted in left supra clavicular area - but soft in consistency and mobile .( ?Lipoma /? Virchows node.) 
No other lymph nodes swelling noted or no palpable breast lumps.
Cvs - s1s2 heard. 
RS- Bae present . No crepitations .
P/A - Soft .
Guarding present. Bowel sounds sluggish.


Reports : Cbp- Hb - 8.8 g/dl
Tlc - 36,000
Plt- 8.48 lakhs.
Pcv - 25.8 - low
mcv - 77.5
NC/NC . 
THROMBOCYTOSIS .

Rft : Urea - 257 ; S creat -13.5 ; Na - 138 ; k-3.9; cl- 98.
Ph - 7.07 ; pco2- 10.9 ; po2- 111 ; st .hco3- 6.2 ; so2- 93.7%.
cue -
 Alb - trace , sugars - nil ; pus cells -2-3 
S .Amylase - 533 ; lipase -180 mg/dl.
Esr - 110 mg/dl
Rbs (outside) - 233 mg/dl .

Usg abdomen - bilateral kidneys decreased size ( 62*23 mm- rt kidney ; lt kidney-65*26 mm) .
Cxr showing fine granular opacities scattered throughout both lung fields.
Ecg - Showing sinus tachycardia.

 Diagnosis : 
Chronic renal failure with uremic encephelopathy .
? Miliary tuberculosis 
? Anemia of chronic disease .

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