40YR OLD FEMALE WITH C/C OF LT SIDED HEMIPLEGIA
Jan05,2021
40 YR FEMALE WITH LT SIDED HEMIPLEGIA
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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 5/5 5/5
LL 5/5 5/5
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
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 5/5 5/5
LL 5/5 5/5
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
Ecg
MRI Brain
MRI Brain with contrast
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
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
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
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 , 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 8hrly
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
COMMENTS
