Case 33 - 40 YR FEMALE WITH QUADREPARESIS

 

40 YR FEMALE WITH QUADREPARESIS 

A 40 yr old female came to opd with C/o giddiness and unable to get up on her own when she woke up today morning unable to stand without support swaing to right side on standing 
C/o fever since yesterday a/w chills, bodypains 
No c/o weakness of limbs,seizures,headache,sensory symptoms 
No c/o burning micturation,cough,SOB,vomiting,loose stools 
No H/o head trauma 
K/c/o DM since 10yrs (diagnosed when pregnant had giddiness and went for checkup) on T.GLUCORYL M1 BD 
K/c/o hypothyroidism since 4yrs on T.Thyronorm 25mg OD 
O/E: 
Pt C/C/C 
Mild pallor+ 
No icterus/cyanosis/clubbing/koilonychia/lymphadenopathy/pedal edema 
Temp: 101°F 
PR: 98 bpm 
BP: 120/80 mmhg 
RR: 18/min 
SPo2: 98 @ RA 
CVS - S1 S2 + 
RS - BAE + 
P/A - soft, non tender 
CNS - 
HMF - intact 
delay in obeying commands 
Cranial nerves - intact 
Power RT LT 
UL 3/5 1/5
LL 3/5 1/5
Tone normal normal 
Reflexes     RT           LT 
     Biceps   2+           2+
    Triceps    1+          1+
 Supinator   1+          1+
         Knee      -             -
        Ankle     -              -
      Plantar  flexor      extensor 
Cerebellar- swaing to Rt side on walking Rombergs - Pt unable to stand 
No nystagmus 







Inv: 
Hb- 7.4 TLC- 6,400 PLT- 2.1 
Smear- microcytic hypochromic anaemia 
Retic count 0.7
Sr.Creat- 1.1 
Sr electrolytes : 
Na -144 
K - 3.9 
Cl -103 
CUE: 
Alb ++ 
Sugar nil
Sr lipid profile:
TC 185
Triglycerides 220
HDLC 37
LDLC 110
VLDLC 44
Sr iron 78

Ecg


2d echo



CXR supine 


MRI Brain with contrast 











Diagnosis: 
ENCEPHALITIS/CERIBRITIS 
ACUTE INFRACT IN RT MEDIAL TEMPORAL POSTERIOR ASPECT OF LENTIFORM NUCLEI with AREAS OF HEMORRHAGIC TRANSFORMATION +


Rx: 
Inj.Mannitol 100ml IV TID
Inj.Pantop 40mg IV OD
Inj.Human Actrapid acc to grbs
Inj.Neomol 1gm IV SOS if temp >101 F
Tab.DOLO 650mg PO TID
IVF NS,RL @75ml/hr
T.Thyronorm 25mg PO OD
Temp/BP/PR monitoring 4th hrly
Grbs monitoring 6th hrly




SOAP Notes 24/12/21
S- fever spikes +, vomitings 3episodes yesterday mng
Lt hemiparesis 
Difficulty in swallowing 

O-
 Pt conscious, oriented to person , not to time and place
Temp - 99f
Bp- 130/90mmhg
PR- 102bpm
RR- 16cpm
Spo2- 97% at ra
Grbs- 222mg/dl
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V3M6
Pupils - b/l reacting to light
Corneal conjuctival- present b/l
Dolls eye- present
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              3/5
LL.         3/5               2/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

Thrombophlebitis + at lt hand region


A-
Acute CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
H/0 type2 DM
H/o hypothyroidism since 4yrs
Anemia ( microcytic hypochromic) under evaluation

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hrly
Inj monocef 1gm iv bd.  D2
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Inj hai SC tid after informing grbs 
Bp / PR / TEMP charting 4th hrly




 25/12/21
SOAP Notes
S- fever spikes +, vomitings subsided, myalgia +

O- Pt conscious, oriented to person , not to time and place
Pallor+
Temp - 99f
Bp- 140/90mmhg
PR- 102bpm
RR- 16cpm
Spo2- 97% at ra
Grbs- 222mg/dl
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Corneal conjuctival- present b/l
Dolls eye- present
Neck stiffness +
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               2/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor
Thrombophlebitis + at lt hand region

A-
Acute CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
? Brain abscess
H/0 type2 DM
H/o hypothyroidism since 4yrs
Anemia ( microcytic hypochromic) under evaluation

P-  planned for MRI Brain with contrast

Rt feeds 100ml milk + protein 
50ml free water.      4th hrly
Inj monocef 2gm iv bd.  D2
Inj metrogyl 500mg iv tid d1
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Inj hai SC tid after informing grbs 
Bp / PR / TEMP charting 4th hrly

26/12/21:

SOAP Notes
S- fever spikes +, headache+, myalgia +

O- Pt conscious, oriented to person , obeying commands
Pallor+
Temp - 100.5f
Bp- 170/90mmhg
PR- 92bpm
RR- 16cpm
Spo2- 97% at ra
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- Lt hemiparesis,oriented to person,obeying commands
Tone-
Rt. Lt
Ul. N Dec
LL. N. Dec
Power
Rt. Lt
UL. 3/5. 1/5
LL. 3/5 2/5
Reflexes
Rt. Lt
Biceps - -
Triceps - -
Supinator - -
Knee- - -
Ankle. - -
Plantar Extensor extensor

Thrombophlebitis + at lt hand region


A-
ENCEPHALITIS/CEREBRITIS 
Acute CVA ( infract in Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
H/0 type2 DM
H/o hypothyroidism since 4yrs
Anemia ( microcytic hypochromic) under evaluation

P-  
Rt feeds 100ml milk + protein 
50ml free water. 4th hrly
Inj meropenem 1 gm iv tid
Inj monocef 2gm iv bd. D2
Inj metrogyl 500mg iv tid d1
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Inj neomol 1gm iv sos
Tab thyronorm 25mcg rt od
Tab amlong 5mg po od
Inj hai SC tid after informing grbs 
Bp / PR / TEMP charting 4th hrly


27/12/21 :
SOAP notes

S- fever spikes +, headache+,severe myalgia+

O- Pt conscious, oriented to person , not to time and place
Pallor+
Temp - 99f
Bp- 130/90mmhg
PR- 102bpm
RR- 16cpm
Spo2- 97% at ra
Grbs- 134mg/dl
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Neck stiffness +
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

Thrombophlebitis + at lt hand region(resolved)

A-
Acute CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
? Encephalitis/cerebrities 
H/0 type2 DM
H/o hypothyroidism since 4yrs
Anemia ( microcytic hypochromic) under evaluation

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hrly
Inj meropenem 1gm iv tid.  D2
Inj metrogyl 500mg iv tid d3
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Inj hai SC tid after informing grbs 
Bp / PR / TEMP charting 4th hrly


28/12/21 :
SOAP Notes

S- fever spikes +,headache+, severe myalgia+
O- Pt conscious, oriented to person , not to time and place
Pallor+
Temp - 99f
Bp- 120/90mmhg
PR- 102bpm
RR- 16cpm
Spo2- 97% at ra
Grbs- 106mg/dl
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Neck stiffness +
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

Thrombophlebitis + at lt hand region(resolved)

A-
Acute CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
? Encephalitis/cerebrities 
H/0 type2 DM
H/o hypothyroidism since 4yrs
Anemia ( microcytic hypochromic) under evaluation

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hrly
Inj meropenem 1gm iv tid.  D3
Inj metrogyl 500mg iv tid d4
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Inj hai SC tid after informing grbs 
Bp / PR / TEMP charting 4th hrly




29/12/21 :
SOAP Notes
S- fever spikes +, headache+,severe myalgia+

O- Pt conscious, oriented to person , not to time and place
Pallor+
Temp - 101f
Bp- 120/90mmhg
PR- 102bpm
RR- 16cpm
Spo2- 97% at ra
Grbs- 108mg/dl
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Neck stiffness +
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

Thrombophlebitis + at lt hand region(resolved)

A-
Acute CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
? Encephalitis/cerebrities 
H/0 type2 DM
H/o hypothyroidism since 4yrs
Anemia ( microcytic hypochromic) under evaluation

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hrly
Inj meropenem 1gm iv tid.  D3
Inj metrogyl 500mg iv tid d4
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Inj hai SC tid after informing grbs 
Bp / PR / TEMP charting 4th hrly



30/12/21:
S- fever spikes +, headache+,severe myalgia+

O- Pt conscious, oriented to person , not to time and place
Pallor+
Temp - 101f
Bp- 120/90mmhg
PR- 102bpm
RR- 16cpm
Spo2- 97% at ra
Grbs- 145mg/dl
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
Acute CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
? Encephalitis/cerebrities 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hrly
Inj meropenem 1gm iv tid.  D4
Inj metrogyl 500mg iv tid d5
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Tab metformin 500mg po od
Bp / PR / TEMP charting 4th hrly



31/12/21:

S- no  fever spikes since yesterday evng,severe myalgia +

O- Pt conscious, oriented to person , not to time and place
Pallor+
Temp - 101f
Bp- 120/90mmhg
PR- 102bpm
RR- 16cpm
Spo2- 97% at ra
Grbs- 145mg/dl
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
H/0 type2 DM
H/o hypothyroidism since 4yrs

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hrly
Inj meropenem 1gm iv tid.  D5
Inj metrogyl 500mg iv tid d6
Inj acyclovir 800mg iv tid d1
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Tab metformin 500mg po od
Bp / PR / TEMP charting 4th hrly



1/1/22:

S- no  fever spikes since yesterday evng,severe myalgia +

O- Pt conscious, oriented to person , not to time and place
Pallor+
Temp - 101f
Bp- 120/90mmhg
PR- 102bpm
RR- 16cpm
Spo2- 97% at ra
Yesterday Pt grbs found be high, urine for ketones- positive .
6u hai iv insulin given and started on insulin infusion
Grbs- 220mg/dl on 3ml/hr
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
Diabetic ketosis 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hrly
Inj meropenem 1gm iv tid.  D5
Inj metrogyl 500mg iv tid d7
Inj acyclovir 800mg iv tid d2
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Bp / PR / TEMP charting 4th hrly
Grbs monitoring hrly



2/1/22:

S- no  fever spikes since yesterday evng,severe myalgia +

O- Pt conscious and irritable , oriented to person  place, not to time
Pallor+
No fever spikes
Temp - 99f
Bp- 120/90mmhg
PR- 102bpm
RR- 16cpm
Spo2- 97% at ra
Yesterday insulin infusiom has been stopped and bridging has been done 
And dosage fixed with nph and regular insulin
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
Diabetic ketosis 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hrly
Inj meropenem 1gm iv tid.  D5
Inj metrogyl 500mg iv tid d7
Inj acyclovir 800mg iv tid d2
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Bp / PR / TEMP charting 4th hrly
Grbs monitoring hrly

3/1/22 :

S- no  fever spikes ,Generalised body pains+,insomnia+

O- Pt conscious and irritable , oriented to person  place, not to time
Pallor+
No fever spikes
Temp - 99f
Bp- 140/90mmhg
PR- 98bpm
RR- 16cpm
Spo2- 97% at ra
insulin infusion  stopped, 
Shifted to regular and NPH insulin 
low blood sugar levels recorded (74mg/dp,76mg/dl)reduced dose of NPH to 12
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
Diabetic ketosis 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hrly
Inj meropenem 1gm iv tid.  D5
Inj metrogyl 500mg iv tid d7
Inj acyclovir 800mg iv tid d2
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Bp / PR / TEMP charting 4th hrly
Grbs monitoring hrly




4/1/22 :
Day 14

S- no  fever spikes ,Generalised body pains+,

O- Pt conscious and irritable , oriented to person  place, not to time
Pallor+
No fever spikes
Temp - 99f
Bp- 130/90mmhg
PR- 98bpm
RR- 16cpm
Spo2- 97% at ra
1 episode of hypoglycemia at 8pm (61mg/dl)
Increased frequency of feeds every 4th hourly 
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
Diabetic ketosis 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hourly
Inj meropenem 1gm iv tid.  D5
Inj metrogyl 500mg iv tid d7
Inj acyclovir 800mg iv tid d2
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Bp / PR / TEMP charting 4th hrly
Grbs monitoring hrly





5/1/22 :
Day 15

S- no  fever spikes ,Generalised body pains+,

O- Pt conscious and irritable ,not oriented to persoon,place and time
Pallor+
No fever spikes
Temp - 99f
Bp- 140/90mmhg
PR- 98bpm
RR- 18cpm
Spo2- 97% at ra
Blood sugar levels spike after her starting on methylprednisolone.
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
Diabetic ketosis 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P- 
Rt feeds 100ml milk + protein 
50ml free water.      4th hourly
Inj meropenem 1gm iv tid.  D5
Inj metrogyl 500mg iv tid d7
Inj acyclovir 800mg iv tid d2
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Bp / PR / TEMP charting 4th hrly
Grbs monitoring hrly



6/1/22 :
Day 16

S- no  fever spikes ,no improvement in sensorium

O- Pt conscious and irritable ,not oriented to person,place and time
Pallor+
No fever spikes
Temp - 99f
Bp- 140/90mmhg
PR- 98bpm
RR- 18cpm
Spo2- 97% at ra
Blood sugar levels controlled 
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
Diabetic ketosis 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P- 
Neurology opinion to be taken and repeat imaging

Rt feeds 100ml milk + protein 
50ml free water.      4th hourly
Inj meropenem 1gm iv tid.  D5
Inj metrogyl 500mg iv tid d7
Inj acyclovir 800mg iv tid d2
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Bp / PR / TEMP charting 4th hrly
Grbs monitoring hrly


7/1/21 :

Day 17

S- no  fever spikes ,no improvement in sensorium

O- Pt conscious and irritable ,not oriented to person,place and time
Pallor+
No fever spikes
Temp - 99f
Bp- 130/90mmhg
PR- 92bpm
RR- 18cpm
Spo2- 97% at ra
Morning grbs 308,16units of actrapid given 
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
Diabetic ketosis 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P- 
Repeat Fundoscopy for raised ICT features

Rt feeds 100ml milk + protein 
50ml free water.      4th hourly
Inj meropenem 1gm iv tid.  D5
Inj metrogyl 500mg iv tid d7
Inj acyclovir 800mg iv tid d2
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Bp / PR / TEMP charting 4th hrly
Grbs monitoring hrly



8/1/22 :
Day 18  

S- no  fever spikes ,no improvement in sensorium

O- Pt conscious and irritable ,not oriented to person,place and time
No improvement in sensorium
Pallor+     
No fever spikes
Temp - 99f
Bp- 160/90mmhg
PR- 92bpm
RR- 18cpm
Spo2- 97% at ra
Morning grbs 112 ,4 units NPH and 8units of actrapid given 
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
Diabetic ketosis(resolved) 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P - watching for further improvement

Rt feeds 100ml milk + protein 
50ml free water.      4th hourly
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Bp / PR / TEMP charting 4th hrly
Grbs monitoring 7 point profile
Tab thyronorm 25mcg RT/OD


9/1/22 :
Day 19

S- no  fever spikes ,no improvement in sensorium

O- Pt conscious and irritable ,not oriented to person,place and time
No improvement in sensorium
Pallor+     
No fever spikes
Temp - 99f
Bp- 140/90mmhg
PR- 92bpm
RR- 18cpm
Spo2- 97% at ra
Morning grbs 110 ,4 units NPH and 8units of actrapid given 
On checking for bedsores- skin excoriation +
Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
Diabetic ketosis(resolved) 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P - watching for further improvement
Ambulate the patient
Physiotherapy 

Change of position every 2nd hourly

Rt feeds 100ml milk + protein 
50ml free water.      4th hourly
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Bp / PR / TEMP charting 4th hrly
Grbs monitoring 7 point profile
Tab thyronorm 25mcg RT/OD


10/1/22 :
Day 20

S- no  fever spikes ,no improvement in sensorium

O- Pt conscious and irritable ,not oriented to person,place and time
No improvement in sensorium
Pallor+     
No fever spikes
Temp - 99f
Bp- 130/80mmhg
PR- 87bpm
RR- 18cpm
Spo2- 97% at ra
Morning grbs 110 ,4 units NPH and 4units of actrapid given 

On checking for bedsores- skin excoriation +
Dressing done

Rs- bae +
Cvs- s1s2+
P/a - soft ,bs +
Cns- GCS : E4V4M6
Pupils - b/l reacting to light
Tone-
             Rt.                 Lt
Ul.          N                Dec
LL.          N.              Dec
Power
             Rt.                 Lt
UL.        3/5.              1/5
LL.         3/5               1/5
Reflexes
            Rt.           Lt
Biceps    -           -
Triceps   -            -
Supinator -           -
Knee-       -           -
Ankle.       -           -
Plantar    Extensor extensor

A-
? Viral encephalitis 
 CVA ( infract in  Rt medial temporal lobe , posterior aspect of Rt lentiform nucleus with hemorrhagic transformation )
Diabetic ketosis(resolved) 
H/0 type2 DM
H/o hypothyroidism since 4yrs

P - watching for further improvement
Ambulate the patient
Physiotherapy 

Change of position every 2nd hourly

Rt feeds 100ml milk + protein 
50ml free water.      4th hourly
Tab amlong 5mg rt od
Inj optineuron 1amp in 100ml NS iv od
Tab atorvas 20mg rt hs
Tab dolo 650mg rt sos
Bp / PR / TEMP charting 4th hrly
Grbs monitoring 7 point profile
Tab thyronorm 25mcg RT/OD


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