Case 33 - 40 YR FEMALE WITH QUADREPARESIS

 

December 23, 2021

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