50/M with progressive supranuclear palsy with status epilepticus secondary to hyponatremia

This  is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 



This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.


Thanks to


Dr. ARCHANA ( INTERN)


Dr. SREEJA  ( INTERN)


Dr . HARSHA  ( INTERN)


Dr. KALYAN ( INTERN)


Dr. SAHITHI ( INTERN)


Dr. JEEHARIKA ( INTERN)




Dr. RAVEEN(PGY1)


Dr. AASHITHA(PGY2)


Dr.ARAVIND( PGY3)


Dr . VAMSHI(PGY3)



Dr. HAREEN(SR)


Dr.PRAVEEN NAIK (ASS.PROF)( duty on call 1)


Dr.RAKESH BISWAS (PROF.AND HOD) ( duty on call 2)


https://archanareddy07.blogspot.com/2021/02/50m-with-parkinsonism.htmlhttps://archanareddy07.blogspot.com/2021/02/50m-with-parkinsonism.html


Dr.ABDUL RAHEEM (INTERN)

Dr.ASHFAQ (INTERN)

Dr.GNANADHA (INTERN)

Dr.SRAVYA (INTERN)

Dr.CHETANA (INTERN)

Dr.NAVYA (INTERN)

Dr.VAMSHI ( PG1)

Dr.SAI CHARAN(PG1)

Dr.SUSMITHA (PG2)

Dr.ADITYA (PG3)

Dr.PRANEETH(PG3)

Dr.PRAVEEN NAIK (ASS.PROF)( duty on call 1)

Dr.RAKESH BISWAS (PROF.AND HOD) ( duty on call 2)


Here is a case i have seen:

Admission under unit 3 on 03/02/2021


Introduction:


Progressive supranuclear palsy (PSP) is a less well-known neurodegenerative brain condition which is sometimes misdiagnosed as Parkinson’s disease or Alzheimer’s.

The presence of a vertical supranuclear gaze palsy and prominent postural instability with falls in the first year of symptoms leads to a diagnosis of clinically probable PSP, and the presence of the balance disorder with slowing of vertical saccades or an isolated supranuclear gaze palsy leads to a diagnosis of clinically possible PSP.

Here we discuss a case of a 50 year old man who presented with frequently closure of eyes, frequent history of falls, tremors and self talk.


Case History:


50 year man, he presented with the complaints of


Frequently walking into objects along with frequent falls since 1.5 years

Drooping of eyelids since 1.5 years

Involuntary movements of hands since 1.5 years 

Talking to self since 1.5 years 


Patient works as a farmer at a local village. He completed his Inter second year. He is the father of 2 children, his elder son works as a salesman at a local company while his younger son stays at home. 

He was a regular alcoholic with daily consumption of toddy and whiskey occasionally. He also used to chew tobacco 5 - 6 times per day. He has stopped alcohol and tobacco consumption since 1 year. 


10 years back, he had a sudden onset of generalised tonic clinic seizure lasting for 2 minutes after getting back from work. He was taken to a local hospital where in he got better after receiving fluids. 


His wife describes him to be an aggressive individual previously and he  would also  throw objects in anger. She says he would often get involved in quarrels. He would get involved in matters which aren't even of his concern. 


2 years back, while he was riding his bike, he had sudden blurring of vision after which he fell from his bike and attained fracture of his left leg for which he got operated. Ever since then, he says he has been having pus discharge on and off from the site of surgery. 

During the hospital stay, he was told that he was a diabetic and was started on Tab Metformin 500mg once daily. 


6 months after the RTA, he started finding it hard to keep his eyes open, he says it progresses as the day passes and it gets aggravated on blinking. 

She says he stopped emotionally expressing himself and would not get involved in conversations with others. He started avoiding people and started being on his own. 

She also says that he started talking to himself and smiling to himself since then. 


He also started walking into things and he would often fall. 

According to his wife and son, he only looks straight ahead while walking without looking sideways. 

He also has been having involuntary movements of bilateral hands which they have noticed on and off, especially while he is doing work.


Since May 2020 he has been having  non productive cough on and off, not associated with wheeze, chest pain, Dyspnea for which he visited a local hospital where in he received certain medications. 


In June 2020, he visited a local hospital again because of non healing ulcer at the site of surgery. 

Few days later in June, he found it difficulty to get up form his bed in the morning after which he was taken to a local hospital where in they were told that he had low levels of potassium in his blood and he was given potassium supplementation. 

In the following 2 months, he continued to feel fatigued for which he visited a local hospital twice where in they were told that he had recurrent episodes of low potassium and had to be on potassium supplementation through out his life.


Over the past few months he has undergone a couple of investigations to figure out the cause of the drooping of his eyelids and sudden change in his behaviour.

Since the last 2 months, he has also been using Trihexyphenydryl 2mg twice daily.


Since the last one year, he also has been having thin stream of urine along with bed wetting at night.


On going through his old reports, he has been having a low Serum potassium of 2.5 since June and has been consistently low ever since.

In Dec 2020, it was 2.8 and in Jan 2020 it was 2.9.

An eeg and a ct brain also was done, which were normal.

History taken by

 Dr. AASHITHA PG - Y2. 



On examination:

Patient is conscious,coherent and cooperative

PR-78bpm

RR-18cpm

BP-130/70mmHg

Afebrile








Reduced arm swing šŸ‘†


CVS- S1 S2+

R/S-BAE+

P/A- Soft, Nontender


CNS Examination :

•MMSE - 30/30






•Motor system : 

-Bulk- no apparent wasting 

-Power- 5/5 in all 4 limbs 

-Tone - increased in all the limbs

-Power - 5/5 in all the limbs

-Reflexes -

 Deep tendon reflexes

  Biceps -3+ in both limbs

  Triceps3+ in both limbs

  Supinator +in both limbs

  Knee 3+ in both limbs

  Ankle -rt 2+ ,left 1+

Superficial reflexes - plantars -b/l flexors

•Cranial nerves -

3rd nerve - 

He is unable to perform upward gaze





ICE PACK TEST : šŸ‘†

Aim- to rule out myasthenia graves for B/L ptosis

Procedure - application of ice to the eyes for 2–5 minutes, ensuring that the ice is covered to prevent ice burns.

Result- no improvement after Ice pack test.

Inference - The results of the test can be deemed positive with a  raise of 2 mm of the palpebral fissure following the removal of the ice pack. The physiological theory is by cooling the tissues, and more specifically the skeletal muscle fibres, the activity of the acetylcholinesterases are inhibited—> increased levels of acetylcholine creating the majority of the improvement.


•All other cranial nerves are intact

•Sensory system - normal.

Examination done by unit-3.


Investigations :: 


CT-Brain:

 



EEG:








 His graphical time line here:



Investigations: done here- 




















We got an Xray done for his left leg which showed non healing fracture which would require the removal of the implant.











Diagnosis: ? Progressive supranuclear palsy

                                             K/C/O type II DM since 2 years

                   


Treatment : 

1 . Tab. SYNDOPA 110mg PO TID
2.  Tab. METFORMIN 500mg PO OD

However, patients with PSP are said to have minimal or no response to levodopa.


The patient fits well into the NIND criteria, after excluding the exclusion criteria.
 Patient discharged on 9th Feb and 
He was on
1 . Tab. SYNDOPA 110mg PO TID
2.  Tab. METFORMIN 500mg PO OD
3. Tab. QUETIAPINEB25 mg OD HS 
4. Syp. ASCORYL 10 ML/PO/TID in one glass of water for one week.

ADMITTED ON 15th  FEB    (MONDAY)

On 14th Feb  -Patient had an episode of vomiting 8 pm followed by sweating, rigidity with the disorientation for half an hour later he had sleep.
 15 th feb  morning he is quite well after evening he had  3 episodes of vomitings ( food and water as contents, non bilious, non blood stained, non projectile )and around 8pm an episode of seizure activity. He brought to casualty in stupor state.
H/o bed soaking present.
Vitals at the time of admission: 
Temp- 98F
Pulse-77 bpm
BP-100/80 mm of hg
RR-20cpm
Spo2- 99%@RA
Grbs-158 mg/dl
CVS- S1,S2 heard,  no murmurs
RS- BAE+, B/L wheeze  - Present.
P/A- soft, obese.
CNS- 
GCS- 3/15, Stuperous
No signs of meningial irritation
Reflex's
                            Right.                Left
Biceps.              3+.                        3+
Triceps.              3+.                       3+
Supinator.           2+.                       2+
Knee.                  3+.                        3+
Ankle                   2+.                       2+
Plantar.              Ext.                      Ext

No cerebral signs.


 At around 11 pm an episode of seizure active noticed on triage bed ( both limbs in tonic clinic state and tounge bite with bleeding present, involuntary micturition present) following this  saturation drops and pulse feeble 5 sets of CPR done.  Femoral pulse - palpable, saturation starts gaining and Patient Intubated.
Investigations-
ECG at admission-
ECG
Chest X ray

Treatment -
1.Inj.MIDAZOLAM 50 mcg / kg /HR= 3 mg/hr=  15 ml/ HR
2.Ryles feeding  with 100 ml of milk every 4th hourly.
3.Air bed with 2 hrly body position change.
4.Inj. PANTOPRAZOLE  40 mg  IV /OD
5.INJ. PHENYTOIN 100 mg IV / TID
6.IVF  2 units RL @ 100 ml / hr
        2 units NS @ 100 ml/hr
7.INJ. HAI SC/ Accordingly.
8.Head up position to 30 degree
9.DVT prophylaxis with limb stockings.
10.Grbs- charting 2 hrly.
11.condom  catherization  done and hrly I/O charting
12.Temp, BP, pr charting 2 hrly 13.Sr. Sodium  chatting 
14.ABG- 12th hrly.



On 16/2
 is on mechanical ventilation

O/e :
Pt unconscious
GCS: 3T
B/L pupil sluggishly reacting to light
ACMV VC MODE
Fio2 90%
PEEP 6
RR 18
VT 420ml

Pt had no fever spikes, not passed stools

Spo2 97%
RR 17/min
PR 95
BP 130/80mmg 

Diagnosis:
Status epilepticus
Post CPR status
progressive supranuclear palsy
Investigations-
Treatment

1.Ryles feeding  with 100 ml of milk every 4th hourly.
2.Air bed with 2 hrly body position change.
3.Inj. PANTOPRAZOLE  40 mg  IV /OD
4..INJ. PHENYTOIN 100 mg IV / TID
5..IVF  2 units RL @ 100 ml / hr
        2 units NS @ 100 ml/hr
6..INJ. HAI SC/ Accordingly.
7.Head up position to 30 degree
8.DVT prophylaxis with limb stockings.
9.Grbs- charting 2 hrly.
10.  hrly I/O charting
11.Temp, BP, pr charting 2 hrly 12.Sr.. Sodium  chatting 
13.ABG- 12th hrly.
14.  3% NaCl infusion @35 ml/HR
15.INJ.KCl  4 amp. In 300 ml RL @4 hours.

On 17/2 
 is on mechanical ventilation CPAP Mode.

O/e :
Pt unconscious
GCS: 7T( E1V1M5)
B/L pupil sluggishly reacting to light.doll's eye +.
Fio2 -21%
PEEP 6
RR 18
Spo2 98%
T- 100.7 F
PR 120/ min
BP 130/80mmg 
Grbs-134 mg/dl

Diagnosis:
Status epilepticus
Post CPR status
progressive supranuclear palsy
Investigations-
Chest X ray-
Treatment:
1.Ryles feeding with 100 ml of milk every 4th hourly.
2.Air bed with 2 hrly body position change.
3.Inj. PANTOPRAZOLE 40 mg IV /OD
4..INJ. PHENYTOIN 100 mg IV / TID
5..IVF 2 units RL @ 150 ml / hr
        2 units NS @ 150 ml/hr
6..INJ. HAI SC/ Accordingly.
7.Head up position to 30 degree
8.DVT prophylaxis with limb stockings.
9.Grbs- charting 2 hrly.
10. hrly I/O charting
11.Temp, BP, pr charting 2 hrly 12.Sr.. Sodium chatting 
13.ABG- 12th hrly.
14.INJ. NEOMOL 1gm IV/ SOS
15.chest physiotherapy after neb. With MUCOMIST.
On 18/2
 is on mechanical ventilation CPAP Mode.

O/e :
Pt unconscious
GCS: 7T( E1V1M5)
B/L pupil sluggishly reacting to light.doll's eye +.
Fio2 -21%
PEEP 5
RR 20
Spo2 98%
T- 101 F
PR 112/ min
BP 110/70mmg 
Grbs-173mg/dl
I/O: 1300/1500

Diagnosis:
Status epilepticus
Post CPR status
progressive supranuclear palsy

Treatment:
1.Ryles feeding with 100 ml of milk every 4th hourly.
2.Air bed with 2 hrly body position change.
3.Inj. PANTOPRAZOLE 40 mg IV /OD
4..INJ. PHENYTOIN 100 mg IV / TID
5..IVF 2 units RL @ 150 ml / hr
        2 units NS @ 150 ml/hr
6..INJ. HAI SC/ Accordingly.
7.Head up position to 30 degree
8.DVT prophylaxis with limb stockings.
9.Grbs- charting 2 hrly.
10. hrly I/O charting
11.Temp, BP, pr charting 2 hrly 12.Sr.. Sodium chatting 
13.ABG- 12th hrly.
14.INJ. NEOMOL 1gm IV/ SOS
15.chest physiotherapy after neb. With MUCOMIST.
16.INJ. THIAMINE 1 amp in 100 ml NS IV/ BD
Investigations-
Lumbar puncture done at L3-L4 
CELL COUNT-
CYTOLOGY-
CSF- Proteins -
Sugars-
ADA-
EEG done  -
In the evening  @4:15 pm after EEG  had an episode of seizure  activity and given lorazepam 4 gm IV stat.
ON 19/2

 is on mechanical ventilation CPAP Mode.

O/e :
Pt unconscious
GCS: 7T( E1 Vt M5)
B/L pupil sluggishly reacting to light.doll's eye +.
Fio2 -21%
PEEP 5
RR 18
Spo2 99%
T- 98.4F
PR 112/ min
BP 140/90mmg 
Grbs-132mg/dl
I/O: 600/1100

Diagnosis:
Status epilepticus
Post CPR status
progressive supranuclear palsy
Treatment:
1.Ryles feeding with 100 ml of milk every 4th hourly.
2.Air bed with 2 hrly body position change.
3.Inj. PANTOPRAZOLE 40 mg IV /OD
4..INJ. PHENYTOIN 100 mg IV / TID
5..IVF 2 units RL @ 150 ml / hr
        2 units NS @ 150 ml/hr
6..INJ. HAI SC/ Accordingly.
7.Head up position to 30 degree
8.DVT prophylaxis with limb stockings.
9. INJ. AUGMENTINE 1.2 gm IV /BD 
10. hrly I/O charting
11.Temp, BP, pr charting 2 hrly.
12.INJ. NEOMOL 1gm IV/ SOS
13.chest physiotherapy after neb. With MUCOMIST.
14.INJ.. THIAMINE 1 amp in 100 ml NS IV/ BD
15.INJ. LEVIPIL 1gm 1 N 100 ml NS in 20 min stat. TO 
INJ. LEVIPIL 500 mg IV /BD

On 20/2
 is on mechanical ventilation CPAP Mode.

O/e :
Pt unconscious
GCS: 8T( E3Vt M5)
B/L pupil sluggishly reacting to light.doll's eye +.
Fio2 -21%
PEEP 5
RR 20
Spo2 97%
T- 101.5F
PR 110/ min
BP 120/80mmg 
Grbs-157mg/dl
I/O: 2300/1250

Diagnosis:
Status epilepticus
Post CPR status
progressive supranuclear palsy
Treatment:
1.Ryles feeding with 100 ml of milk every 4th hourly.
2.Air bed with 2 hrly body position change.
3.Inj. PANTOPRAZOLE 40 mg IV /OD
4..INJ. PHENYTOIN 100 mg IV / TID
5..IVF 2 units RL @ 150 ml / hr
        2 units NS @ 150 ml/hr
6..INJ. HAI SC/ Accordingly.
7.Head up position to 30 degree
8.DVT prophylaxis with limb stockings.
9. INJ. CEFTRIAXONE 1gm /IV /BD
10. hrly I/O charting
11.Temp, BP, pr charting 2 hrly.
12.INJ. NEOMOL 1gm IV/ SOS
13.chest physiotherapy after neb. With MUCOMIST.
14.INJ.. THIAMINE 1 amp in 100 ml NS IV/ BD

Investigations-

 On 21/2
   is on mechanical ventilation CPAP Mode.

O/e :
Pt unresponsive
GCS: 8T( E3Vt M5)
B/L pupil sluggishly reacting to light.doll's eye +.
Fio2 -21%
PEEP 5
RR 26
Spo2 97%
T- 103 F
PR 110/ min
BP 150/90mmg 
Grbs-138mg/dl
I/O: 3800/1600
Stools not passed since 4 days
Diagnosis:
Status epilepticus Secondary to hyponatremia
Post CPR status
progressive supranuclear palsy and type 2 DM


Treatment:
1.Ryles feeding with 100 ml of milk every 4th hourly.
2.Air bed with 2 hrly body position change.
3.Inj. PANTOPRAZOLE 40 mg IV /OD
4..INJ. PHENYTOIN 200 mg IV / TID
5..IVF 2 units RL @ 75ml / hr
        2 units NS @ 75 ml/hr
6..INJ. HAI SC/ Accordingly.
7.Head up position to 30 degree
8.DVT prophylaxis with limb stockings.
9. INJ. AUGMENTIN 1.2 gm /IV /BD D2
10. hrly I/O charting
11.Temp, BP, pr charting 2 hrly.
12.INJ. NEOMOL 1gm IV/ SOS
13.chest physiotherapy after neb. With MUCOMIST.
14.INJ.. THIAMINE 1 amp in 100 ml NS IV/ BD
15. INJ. LEVIPIL  500 mg IV BD
16.Oint. THROMBOPHOBE for L/A
17.Neb. BUDECORT 12th hrly, MUCOMIST 6th hrly
18.ET suction  2hrly.
EXTUBATED @ 6:30 PM 

On day 22/2
Fever spikes present, stools not passed.
O/e :
Pt conscious
GCS: 9( E3V1 M5)
B/L pupil sluggishly reacting to  light.
T- 103 F
PR 130/ min
BP 140/90mmg
RR- 26
Spo2 97%
Grbs-134mg/dl
I/O: 2900/2150
CVS- S1,S2 +
RS- BAE +
P/A - soft, non tender.
Diagnosis:
Status epilepticus Secondary to hyponatremia
Post CPR status
progressive supranuclear palsy and type 2 DM


Treatment:
1.Ryles feeding with 100 ml of milk every 4th hourly.
*O2 inhalation to maintain spo2- More than 92%
2.Air bed with 2 hrly body position change.
3.Inj. PANTOPRAZOLE 40 mg IV /OD
4..INJ. PHENYTOIN 200 mg IV / TID
5..IVF 2 units RL @ 75ml / hr
        2 units NS @ 75 ml/hr
6..INJ. HAI SC/ Accordingly.
7.Head up position to 30 degree
8.DVT prophylaxis with limb stockings.
9. INJ. AUGMENTIN  1.2gm /IV /BD D3
10. hrly I/O charting
11.Temp, BP, pr charting 2 hrly.
12.INJ. NEOMOL 1gm IV/ SOS
13.chest physiotherapy after neb. With MUCOMIST.
14.INJ.. THIAMINE 1 amp in 100 ml NS IV/ BD
15. INJ. LEVIPIL  500 mg IV BD
16.Oint. THROMBOPHOBE for L/A
17.Neb. IPRAVENT, BUDECORT 12th hrly, MUCOMIST 6th hrly

On day 23/2
No fever spikes, stools passed yesterday.

O/e :
Pt conscious
GCS: 9( E3V1 M5)
B/L pupil sluggishly reacting to light.
T- 98.4F
PR 118/ min
BP 100/70mm of hg
RR- 26
Spo2 98% @ 6 litres of O2
Grbs-154mg/dl
I/O: 2500/1000
CVS- S1,S2 +
RS- BAE +
P/A - soft, non tender.
Diagnosis:
Status epilepticus Secondary to hyponatremia
Post CPR status
progressive supranuclear palsy and type 2 DM


Treatment:
1.Ryles feeding with 100 ml of milk every 4th hourly.
*O2 inhalation to maintain spo2- More than 92%
2.Air bed with 2 hrly body position change.
3.Inj. PANTOPRAZOLE 40 mg IV /OD
4..INJ. PHENYTOIN 200 mg IV / TID
5..IVF 2 units RL @ 75ml / hr
        2 units NS @ 75 ml/hr
6..INJ. HAI SC/ Accordingly.
7.Head up position to 30 degree
8.DVT prophylaxis with limb stockings.
9. INJ. AUGMENTIN 1.2gm /IV /BD D4
10. hrly I/O charting
11.Temp, BP, pr charting 2 hrly.
12.INJ. NEOMOL 1gm IV/ SOS
13.chest physiotherapy after neb. With MUCOMIST.
14.INJ.. THIAMINE 1 amp in 100 ml NS IV/ BD
15. INJ. LEVIPIL 500 mg IV BD
16.Oint. THROMBOPHOBE for L/A
17.Neb. IPRAVENT, BUDECORT 12th hrly, MUCOMIST 6th hrly

On day 24/2
C/o seizures 3-4 episodes.
 fever spike - present(@4pm),


O/e :
Pt is drowsy
GCS: 10( E3V2 M5)
B/L pupil sluggishly reacting to light.
T- 99F
PR 118/ min
BP 110/70mm of hg
RR- 26
Spo2 98% @ 6 litres of O2
Grbs-153mg/dl
I/O: 1800/500
CVS- S1,S2 +
RS- BAE +
P/A - soft, non tender.
Diagnosis:
Status epilepticus Secondary to hyponatremia
Post CPR status
progressive supranuclear palsy and type 2 DM


Treatment:
1.Ryles feeding with 100 ml of milk every 4th hourly.
*O2 inhalation to maintain spo2- More than 92%
2.Air bed with 2 hrly body position change.
3.Inj. PANTOPRAZOLE 40 mg IV /OD
4..INJ. PHENYTOIN 200 mg IV / TID
5..IVF 2 units RL @ 75ml / hr
        2 units NS @ 75 ml/hr
6..INJ. HAI SC/ Accordingly.
7.Head up position to 30 degree
8.DVT prophylaxis with limb stockings.
9. INJ. AUGMENTIN 1.2gm /IV /BD- D5
10. hrly I/O charting
11.Temp, BP, pr charting 2 hrly.
12.INJ. NEOMOL 1gm IV/ SOS
13.chest physiotherapy after neb. With MUCOMIST.
14.INJ.. THIAMINE 1 amp in 100 ml NS IV/ BD
15. INJ. LEVIPIL 500 mg IV BD
16.Oint. THROMBOPHOBE for L/A
17.Neb. IPRAVENT, BUDECORT 12th hrly, MUCOMIST 6th hrly
18. INJ.CLINDAMYCIN 600 mg IV/BD D1
19. INJ. MODAFENIL 200 mg OD for 2 days @ 4pm

On day 25/2
C/o seizures 3-4 episodes.
 fever spike - present(@4pm),


O/e :
Pt is drowsy
GCS: 10( E3V2 M5)
B/L pupil sluggishly reacting to light.
T- 99F
PR 118/ min
BP 110/70mm of hg
RR- 26
Spo2 98% @ 6 litres of O2
Grbs-153mg/dl
I/O: 1800/500
CVS- S1,S2 +
RS- BAE +
P/A - soft, non tender.
Diagnosis:
Status epilepticus Secondary to hyponatremia
Post CPR status
progressive supranuclear palsy and type 2 DM


Treatment:
1.Ryles feeding with 100 ml of milk every 4th hourly.
*O2 inhalation to maintain spo2- More than 92%
2.Air bed with 2 hrly body position change.
3.Inj. PANTOPRAZOLE 40 mg IV /OD
4..INJ. PHENYTOIN 200 mg IV / TID
5..IVF 2 units RL @ 75ml / hr
        2 units NS @ 75 ml/hr
6..INJ. HAI SC/ Accordingly.
7.Head up position to 30 degree
8.DVT prophylaxis with limb stockings.
9. INJ. AUGMENTIN 1.2gm /IV /BD- D5
10. hrly I/O charting
11.Temp, BP, pr charting 2 hrly.
12.INJ. NEOMOL 1gm IV/ SOS
13.chest physiotherapy after neb. With MUCOMIST.
14.INJ.. THIAMINE 1 amp in 100 ml NS IV/ BD
15. INJ. LEVIPIL 500 mg IV BD
16.Oint. THROMBOPHOBE for L/A
17.Neb. IPRAVENT, BUDECORT 12th hrly, MUCOMIST 6th hrly
18. INJ.CLINDAMYCIN 600 mg IV/BD D1
19. INJ. MODAFENIL 200 mg OD for 2 days @ 4pm

On day 25/2


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