Feverprojr LEPTO 37/M

 leptospirosis- 

date of admission 21/6/2022

date of discharge 25/06/2022

?VIRAL ENCEPHALITIS

?LEPTOSPIROSIS

?QUADRIPARESIS SECONDARY TO AMSAN

Case History and Clinical Findings

PT CAME TO THE CASUALTY WITH ALTERED SENSORIUM AND QUADRIPARESIS AND C/O FEVER SINCE 15 DAYS AND WEAKNESS OF UPPER AND LOWER LIMBS SINCE 10 DAYS AND HAS ALTERED SENSORIUM SINCE 10 DAYS.

PT WAS APPARENTLY ASYMPTOMATIC 15 DAYS AGO AND THEN DEVELOPED FEVER WHICH WAS INTERMITTENT AND RELIEVED ON MEDICATION , WEAKNESS OF B/L UPPER LIMBS AND LOWER LIMBS WITH DECRESED TONE AND DECREASED POWER. DEVELOPMENTAL DELAY OF MILE STONES IN HIS CHILDHOOD(WALKED AT 6 YRS OF AGE).

K/C/O EPILEPSY SINCE THE PT WAS 6 MONTHS AGE

NOT A K/C/O HTN DM TB CAD ASTHMA

O/E

PT IS CONSCIOUS

CVS - S1 S2 +

RA - BAE+

CNS - E4V2M1

P/A - SOFT

VITALS-

PR90 BPM

BP- 150/80 MMHG

SPO2 - 95% ON 10 L OF O2.

Treatment Given(Enter only Generic Name)

RT FEEDS BEEN GIVEN (100ML MILK + PROTEIN AND 100 ML WATER)

INJ.MONOCEF 2GM IV BD

INJ. DEXA 8 MG IV TID

INJ.DOXY 100MG IV BD

INJ.ACYCLOVIR 500MG IV TID

IVF DNS AND RL AT 50ML/HR

INJ.PAN 40 MG IV OD

TAB.DOLO 650 MG RT TID

INJ NEOMOL IV SOS

TEPID SPONGING

GRBS CHARTING 6 TH HRLY

MONITOR VITALS 1 HRLY

TEMP CHARTING 1 HRLY

Advice at Discharge

PT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE PATIENT CONDITION AND NEDD FOR FURTHER HOSPITAL STAY BUT THE ATTENDERS WANT TO LEAVE AGAINST THE MEDICAL ADVICE DUE TO PERSONAL REASONS.