THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[16-06-2025 13.23] PPM 1: OPD now
52F with anger issues since 2021. Got operated for thyrotoxicosis in 2023 and currently having progressively worsening gait noticed by family members since May 2025.
[18-06-2025 07:25] PPM 1: Morning CBBLE session around this patient:
[17/06, 22:51] +91 pan India clinical discussion fora: What was the cause here
[18/06, 07:17]cm: The video shows a broad based ataxic gait that on further examination revealed more cerebellar signs in the form of intention tremors and dysdiadochokinesia.
Her anger issues since 2021 got resolved on psycho pharmacological Mx even as she got operated for thyrotoxicosis in 2023 and it's intriguing as to why she's currently having progressively worsening gait noticed by family members since May 2025 although her cranial MRI is normal suggesting that her cerebellar abnormalities could be early and possibly due to a demyelinating cause.
Is there a connection between thyrotoxicosis and cerebellar involvement? @PPM3 @PPM6
[18/06, 07:18] cm : @Meta AI any studies showing a connection between thyrotoxicosis and progressive cerebellar signs and symptoms?
[18/06, 07:18] Meta AI: Thyrotoxicosis can indeed cause cerebellar symptoms, including ataxia, due to the impact of excessive thyroid hormones on the nervous system. Research suggests that thyroid disorders, such as hypothyroidism and hyperthyroidism, are linked to cerebellar dysfunction.
Key Findings:
- Cerebellar Syndrome: Thyroid disorders are considered a common cause of cerebellar dysfunction due to hormonal imbalance. Cerebellar impairment often occurs in hypothyroidism and Hashimoto encephalopathy.
- Symptoms: Patients may exhibit ataxic gait, intention tremors, dysdiadochokinesia, and other cerebellar signs.
- Reversibility: Some studies suggest that cerebellar symptoms may improve with normalization of thyroid hormone levels, but persistent or progressive symptoms can occur, raising questions about long-term effects or co-existing conditions.¹ ²
Possible Causes and Associations:
- Thyroid Hormone Imbalance: Excessive thyroid hormones can affect the cerebellum, leading to impaired coordination and balance.
- Autoimmune Conditions: Conditions like Graves' disease and Hashimoto encephalopathy may contribute to cerebellar dysfunction.
- Other Factors: Certain medications, infections, and systemic conditions can also play a role in cerebellar symptoms.³
Further Investigation:
Given the complex relationship between thyrotoxicosis and cerebellar involvement, further evaluation is necessary to determine the underlying cause of progressive cerebellar symptoms. This may include⁴:
- Genetic Testing: To rule out genetic ataxias or other conditions.
- Imaging Studies: Such as MRI to assess cerebellar structure and function.
- Laboratory Tests: To evaluate thyroid function and other potential contributing factors.
In conclusion, while the exact relationship between thyrotoxicosis and cerebellar involvement is not fully understood, research suggests a link between thyroid disorders and cerebellar dysfunction. Further investigation is necessary to determine the underlying cause of progressive cerebellar symptoms in individual cases.
[18-06-2025 07:25] PPM 1: @PPM5 please share her current thyroid function tests
[18-06-2025 07:27] PPM 3: Will do a literature review today and share my findings sir
[18-06-2025 07:28] PPM 5: By afternoon the report will come sir
[18-06-2025 07:47] PPM 1: Also share the patient's full history timeline so that @CR can archive it in the case report
[18-06-2025 08:06] PPM 1: CBBLE discussion continued:
[18/06, 07:56] +91 hu2: What I am thinking is it is not due to cerebellar lesion but due to drug causing EPS, won't be appropriate to check patient for cerebellar signs, what I suggest stop olanzapine and evaluate.
[18/06, 07:58] +91 hu2: We can tapper olanzapine and shift her on Fluoxetine.....
[18/06, 07:58] +91 hu2: Than evaluate....
[18/06, 08:00]cm: @PPM3 please share what psychiatric medications she's taking.
One of the reasons for calling her again to OPD from her wards yesterday was to review these but couldn't be done as they didn't bring the papers
[18/06, 08:02] +91pan india clinical discussion fora hu2: Or what else we can do if is it demylenating disorder as seen in along with autoimmune hyperthyroidism, than we can also have trial of IV steroid to see the effects.
[18/06, 08:03]cm: EPS was an important first possibility cognitive bias we had while evaluating her but then her cerebellar signs were too dominant to be able to ignore
[18/06, 08:04]cm: Yes one of the reasons for her admission is to go ahead with the iv steroid trial
[18-06-2025 14:45] PPM 1: Update from @PPM3's evaluation yesterday:
She was on Olanzapine 7.5mg taken at night, with Clonazepam 0.25mg SOS.
However, her most recent psychiatry review notes (dated 22/4/2025) say that she was not compiant with medication for a while due to financial issues.
In 2021, when her psychosis diagnosis was made, she was also on Fluoxetine. It was slowly tapered from 40mg to 20mg, and then stopped after some time.
[18-06-2025 14:46] PPM 4: •Any previous MRI of Brain
•Any ischemia? (post operative thyroid sx)
•Does she have any unhealed trauma?
[18-06-2025 14:47] PPM 1: MRI normal
[18-06-2025 14:47] PPM 4:? Psychiatric h/o sir
Today's thyroid report
[18-06-2025 15:14] PPM 4: What kind of thyroid surgery sir, any Discharge summary after surgery.
[18-06-2025 15.15] PPM 1: Total thyroidectomy
[18-06-2025 16.12] PPM 1: This is where her history begins on 3/3/21👆
On Olanzepine since then
[18-06-2025 16:17] PPM 4: Sir did psychiatric symptoms start before surgery?
i think thyroid harmonal imbalance caused her psychosis
[18-06-2025 16:17] PPM 1: Yes
[18-06-2025 16.18] PPM 1: This is her first OPD visit after the surgery
[18-06-2025 16:18] PPM 4: Sir I think we just need to balance those harmones
and maintain them in normal levels gradually
[18-06-2025 16:19] PPM 4: And also give her psychiatric medication for current symptoms.
[18-06-2025 16.20] PPM 1: So to balance the hormones the entire thyroid gland was removed and thyroxine replacement was started since post surgery May 2023
[18-06-2025 16:20] PPM 1: And what about her gait? Did you see the video in the case report?
[18-06-2025 16:23] PPM 4: Can psychiatric medications dose might have caused it (cerebellar gait as said in video) adjust the dose of psychiatric medications and also psychotherapy is needed.
[18-06-2025 16:34] PPM 1: No such olanzepine induced cerebellar disturbances reported in the past globally but it's possibly due to immune mediated cerebellar dysfunction as you will find in the case report archived link in the description box. Even queries have been archived there!
[18-06-2025 16:40] PPM 4: I think i need more knowledge to read these images 😅
[18-06-2025 16:40] PPM 4: I haven't revised my radiology yet
will try to find it
[18-06-2025 16:43] PPM 1: Just normal anatomy
Nowadays LLMs can read better @PPM 7
[18-06-2025 16:45]PPM 4: 😅😅
i just don't want to make a mistake
on my input
[18-06-2025 16:46] PPM 1: No problem there are many team members who will correct and most importantly we have LLMs here
[18-06-2025 16:48] PPM 4: LLMs means 😅
[18-06-2025 16:50] PPM 1: @Meta AI what does LLM mean? What are you?
[18-06-2025 16:50] Meta AI: LLM stands for Large Language Model. I'm Meta AI, powered by Llama 4. Think of me like a super-smart computer program that can understand and respond to human language. I'm here to help with whatever you need, whether it's answering questions, generating text, or just chatting 🤖💻. What's on your mind?
[18-06-2025 16:50] PPM 4: I'm just a MBBS graduate sir
[18-06-2025 16:51] PPM 1: School students can do what we are doing. Very near future alk these will be practiced in school by citizen astronauts
[18-06-2025 16:51] PPM 4: Yeah
[18-06-2025 17:40] PPM 4: All? 😅
[18-06-2025 17:46] PPM 1: All
[18-06-2025 17:47] PPM 4: Got it
[18-06-2025 17:47] PPM 4: U tested me a lot 😅😅
whether I'm using ai or not.
genuinely haven't used AI to answer or raise questions
[18-06-2025 17:48] PPM 4: Just using my ongoing Neet pg prep knowledge 😅
[18-06-2025 17:49] PPM 4: Im trying to see the patient beyond their labels
and where the imbalance is and what might have caused it
[18-06-2025 17:49] PPM 4: Where can we adjust it
[18-06-2025 17:50] PPM 4: I don't know exact doses and all the minute details..
but yeah i tried to genuinely answer ur Tests
[21-06-2025 08:30] PPM 1: @PPM8 can you please share this patient's IP number too in pm?
[21-06-2025 08:31] PPM 8: Ok sir...i will find it out and share
[21-06-2025 08:39] PPM 1: Meanwhile @CR here's her past EMR summary when she was admitted for thyroidectomy with surgery 👇
Age/Gender: 49 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 10/04/2023 11:35 AM
Date of Operation
15/04/23
TOTAL THYROIDECTOMY DONE UNDER GENERAL ANAESTHESIA ON 15/04/2023
Name of Treating Faculty
DR. RK
Diagnosis
MULTINODULAR GOITRE
Case History and Clinical Findings
C/O BLOOD IN SPUTUM SINCE 1 MONTH
C/O SWELLING IN FRONT OF NECK SINCE 10 YEARS
HISTORY OF PRESENTING ILLNESS :
PATIENT WAS APPARENTLY ASYMPTOMATIC 10 YEARS BACK, THEN SHE DEVELOPED A
SWELLING WHICH WAS OF 1X1 CM, WHICH GRADUALLY DEVELOPED IN SIZE AND
ATTAINED TO PRESENT SIZE OF 4X3CM
C/O BLOOD IN SPUTUM SINCE 1 MONTH
H/O LOSS OF APPETITE PRESENT
NO H/O SIMILAR COMPLAINTS IN PAST
NO H/O WEIGHT LOSS, SIMILAR COMPLAINTS IN PAST, DIFFICULTY IN SWALLOWING,
ABNORMAL SPEECH, HOARSENESS OF VOICE OR ANY COMPRESSIVE SYMPTOMS
PAST HISTORY :
K/C/O PSYCHOSIS PREVIOUSLY ON TREATMENT WITH TAB OLANZAPINE2-5 MG, TAB
FLUOXETINE 4MG
N/K/C/O DM, HTN, BA, CAD, CAD, CVD
Page-2
KIMS HOSPITALS
UNDERWENT HYSTERECTOMY + LEFT OOPHERECTOMY 11 YEARS AGO
PERSONAL HISTORY:
NORMAL APPETITE
MIXED DIET
BOWEL AND BLADDER REGULAR
SLEEP ADEQUATE
FAMILY HISTORY : NOT SIGNIFICANT
GENERAL EXAMINATION:
PATIENT IS C/C/C
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA.
VITALS: TEMP: 98.3 F
PR:78 BPM
BP:110/70
RR: 18CPM
SPO2: 99%
GRBS:104MG%
SYSTEMIC EXAMINATION:
CVS: S1,S2 +
CNS: NAD
RS: BAE+, NAD
P/A - NON TENDER, NO ORGANOMEGALY, SOFT, BS +
LOCAL EXAMINATION OF NECK
INSPECTION:
A SOLITARY NODULE NOTED ON ANTERIOR ASPECT OF NECK OF 5X3CM IN SIZE AND
CIRCULAR SHAPE
SKIN AND SURROUNDING TISSUE APPEARS TO BE NORMAL
SWELLING MOVES UP ON DEGLUTITION
NO ENGORGED VEINS OR OTHER INSIGNIFICANT CHANGES
Page-3
KIMS HOSPITALS
PALPATION:
TENDERNESS ABSENT
NO LOCAL RISE OF TEMPERATURE
ALL INSPECTORY FINDINGS CONFIRMED ON PALPATION
SKIN PINCHABLE
MOBILE IN ALL DIRECTIONS
FIRM TO HARD IN CONSISTENCY
PSYCHIATRY REFERRAL 12/4/23
REFERRAL I/V/O STOPPED MEDICATIONS 2 MONTHS AGO
ADVISED - PATIENT WITH ATTENDERS COUNSELLED REGARDING THE NEED TO BE
COMPLIANT WITH MEDICATION
TAB OLANZAPINE 2.5MG - ATTENDER SUPERVISED MEDICATION
ENT REFERRAL 11/4/23
REFERRAL I/V/O INDIRECT LARYNGOSCOPY
B/L VOCAL CORDS MOBILE AND SYMMETRICAL
B/L NO POOLING OF SALIVA IN PYRIFORM FOSSA
Investigation
USG NECK 11/4/23
THYROID GLAND 38X25X46MM RIGHT LOBE
ISTHMUS 11 MM
LEFT LOBE 32X24X46MM
E/O MULTIPLE SOLID NODULES NOTED IN BOTH LOBES OF THYROID GLAND, LARGEST
MEASURING 32X20MM IN RIGHT LOBE WHICH IS WELL DEFINED, WIDER THAN TALLER,
ISOECHOIC WITH INCREASED VASCULARITY AND NO CALCIFICATION
27X19MM ISOECHOIC NODULE IN LEFT LOBE WHICH IS WIDER THAN TALLER WITH
INCREASED VASCULARITY AND NO CALCIFICATION
TIRADS III LESION
B/L SUBMANDIBULAR GLANDS NORMAL, B/L CAROTID AND JUGULAR VESSELS NORMAL,
FEW PROMINENT LYMPH NODES NOTED B/L AT LEVEL II, III, IV. LARGEST MEASURING 4-
5MM AT LEVEL II ON LEFT SIDE
IMPRESSION:
Page-4
KIMS HOSPITALS
TIRADS III LESION IN BOTH LOBES OF THYROID GLAND
PROMINENT CERVICAL LYMPHADENOPATHY
CYTOLOGY - USG GUIDED FNAC 11/4/23
IMPRESSION - FEATURES SUGGESTIVE OF BETHESDA CATEGORY II ( NODULAR COLLOID
GOITRE)
10/4/23
RBS - 91MG/DL
PT - 17 SEC
INR - 1.25
BGT - B POSITIVE
BT/CT - 2MIN/ 4MIN 30 SEC
APTT - 35 SEC
Treatment Given(Enter only Generic Name)
INJ TAXIM 1GM IV/BD
INJ HYDROCORTISONE 100MG IV/OD
TAB PAN 40MG PO/OD
INJ PCM 1GM/IV/TID
INJ CALCIUM GLUCONATE 1 AMP IN 100ML NS SLOW /OD
INJ ZOFER 4MG IV/SOS
TAB THYRONORM 37.5 MCG PO/OD/BBF
TAB CHYMORAL FORTE PO/TID
SYRUP CREMAFFIN 10ML PO/BD IN 1 GLASS OF WATER
NEBULIZATION WITH DUOLIN BUDECORT
Advice at Discharge
TAB THYRONORM 37.5 MCG PO/OD/BBF
TAB TAXIM 200MG PO/BD X 3 DAYS
TAB PAN 40MG PO/OD/BBF X 3 DAYS
TAB MVT PO/OD X 3 DAYS
TAB VIT C PO/OD X 3 DAYS
TAB OLANZAPINE 2.5MG/HS
TAB SHELCAL PO/OD X 2 MONTHS
Page-5
KIMS HOSPITALS
Follow Up
REVIEW SOS
REVIEW TO GENERAL SURGERY OPD FOR SUTURE REMOVAL IN 10-14 DAYS
REVIEW TO PSYCHIATRY OPD AFTER 2 WEEKS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
For Treatment Enquiries Patient/Attendent Declaration: - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date:20/4/2023
Ward: FSW
Unit:1
[21-06-2025 08:40] PPM 1: @PPM8 we asked our PGs and interns from that unit to find out the biopsy report of what the surgeons had sent on 15/4/23 but none of them could find it. Do you think you may be able to help?
[21-06-2025 08:41] PPM 8: Once I will try Sir. and let you know if there is anything.
[21-06-2025 08:43] PPM 1: Thanks
[21-06-2025 10:23] PPM 1: @CR current EMR summary by unknown intern 👇
Age/Gender: 52 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 16/06/2025 03:09 PM
Name of Treating Faculty
(AP), (SR)
Diagnosis
PSYCHOSIS NOT OTHERWISE SPECIFIED SINCE 2023
CEREBELLAR ATAXIA SINCE 2 MONTHS
?DRUG INDUCED ?VITB12 DEFICIENCY ?DEMYELINATION
Case History and Clinical Findings
C/O GAIT DISTURBANCES SINCE 1 MONTH
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 1MONTH BACK, THEN SHE WAS UNABLE TO WALK, WHICH WAS INSIDIOUS IN ONSET, PROGRESSIVE IN NATURE, WENT TO NEUROOGY OPD AND WAS TREATED WITH VITAMIN B12 DEFICIENCY .10 DAYS AFTER VITAMIN B12 INJECTIONS, PATIENT IMPROVED SYMPTOMATICALLY, AND WAS ABLE TO WALK WITH SUPPORT .
NO H/O FEVER, LOOSE STOOLS, VOMITINGS.
NO H/O OUTSIDE FOOD INTAKE.
C/O VISUAL AND AUDITORY HALLUCIANTIONS SINCE 2021, ON AND OFF EPISODES AND
LATER THE PATIENT BEHAVIOUR WAS ALTERED AND PATIENT STARTED SCOLDING
OTHERS. SHE HAS ANGER ISSUES SINCE 2021.
PAST ILLNESS: H/O PSYCHOSIS SINCE 12YRS (USED TAB.OLANZAPINE 5MG(X-X-1/2))
CEREBELLAR ATAXIA SINCE 2021.
K/C/O HYPOTHYROIDISM SINCE 2023 ON TAB.THYRONORM 100MCG PO/OD IHR BBF
N/K/C/O DM-II, ASTHMA, TB
SURGICAL HSTORY: HYSTERECTOMY DONE 10YRS BACK KIMS HOSPITALS
PERSONAL HISTORY: MARRIED, NORMAL APPETITE, MIXED DIET, REGULAR BOWEL AND BLADDER MOVEMENTS, NORMAL MICTURITION, NO ALLERGIES, SLEEP ADEQUATE, NO ADDICTIONS
FAMILY HISTORY: NOT SIGNIFICANT
GENREAL EXAMINATION: NO PALLOR, ICTERUS, CYANOSIS, CLUBBING,
LYMPHADENOPATHY, MALNUTRITION
VITALS: - TEMP: AFEBRILE, BP: 110/70 MMHG, RR: 16CPM, PR:99 BPM, SPO2: 98% AT RA,
GRBS 118 MG%
SYSTEMIC EXAMINATION:- CVS, RS , P/A: NORMAL
CNS :- HIGHER MENTAL FUNCTIONS INTACT, NO FOCAL NEUROLOGICAL DEFICIT
TONE- RIGHT LEFT
UL NORMAL NORMAL
LL NORMAL NORMAL
POWER- RIGHT LEFT
UL 5/5 5/5
LL 5/5 5/5
REFLEXES:
BICEPS +2 +2
TRICEPS +1 +1
SUPINATOR + +
KNEE +2 +2
ANKLE + +
PLANTAR FLEXOR FLEXOR
CEREBELLAR EXAMINATION
GAIT-WIDE BASED SHORT STEPS
1.TIBUTATION-ABSENT
2.TRUNCAL ATAXIA/GAIT ATAXIA-POSITIVE
3.NYSTAGMUS ABSENT
4.DYSARTHRIA-ABSENT
5.DYSTONIA-ABSENT
6.REBOUND PHENOMENON-PRESENT
7.INTENTIONAL TREMORS-POSITIVE
8.PENDULAR KNEE JERK-NEGATIVE
9.TANDEM WALKING-NGATIVE
10.COORDINATION
a) UPPERLIMBS-FINGER NOSE TEST INCOORDINATION SLOW
b) LOWERLIMBS-KNEE HEEL TEST ABSENT
11. RHOMBERGS POSITIVE-SWAYING WHILE CLOSING EYES
COURSE IN HOSPITAL:
A 52YR OLD
Investigation
ON 16/6/25
COMPLETE URINE EXAMINATION COLOUR Pale yellow APPEARANCE Clear REACTION
Acidic SP.GRAVITY 1.010ALBUMIN +SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil
BLOOD UREA 21 mg/dl SERUM CREATININE 0.8 mg/dl
SERUM ELECTROLYTES SODIUM 136 mmol/L POTASSIUM 3.8 mmol/L CHLORIDE 101 mmol/L HBsAg-RAPID Negative, Anti HCV Antibodies - RAPID Non Reactive
LIVER FUNCTION TEST
Total Bilirubin 0.64 mg/dl
Direct Bilirubin 0.20 mg/dl SGOT(AST) 34 IU/L
SGPT(ALT) 33 IU/L ALKALINE PHOSPHATASE 245 IU/L TOTAL PROTEINS 7.5 gm/dl
ALBUMIN
4.5 gm/dl A/G RATIO 1.51
T3, T4, TSHT3 1.12 ng/ml T4 16.93 micro g/dl TSH 0.008 micro Iu/ml
Treatment Given (Enter only Generic Name)
TAB.THYRONORM 100MCG PO/OD 1HR BBF(7AM-X-X)
TAB.MVT PO/OD/2PM(X-2PM-X)
Follow Up
REVIEW TO GM OPD AFTER 15 DAYS/SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
For Treatment Enquiries Patient/Attendent Declaration: - The medicines prescribed
and the advice regarding preventive aspects of care, when and how to obtain urgent care have been
explained to me in my own language SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF
PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
** Tentative Date Page-3KIMS HOSPITALS
Discharge Date
Date: Ward: Unit:
[21-06-2025 17.05] PPM 8: Goodevening sir
It was given as nodular goitre of both rt and lt thyroid lobes.
[21-06-2025 17.05] PPM 1: Thanks. This is the microscopic finding?
So malignancy is ruled out?
[21-06-2025 17.05] PPM 8: Yes sir
[24-06-2025 14.36] PPM 1: There's this additional data in the discharge I just noticed that wasn't included previously in the one above shared Saturday.The fact that she was given empirical iv methyl prednisolone as per neurology advice wasn't mentioned earlier above but is attached
[24-06-2025 14.46] PPM 1: Chat GPT converted the image to text 👇
[24/06, 14:37] ChatGPT: Here’s a summary of the case from the image:
- Psychiatry referral: Done on 19/06/25 → started on Olanzapine 2.5 mg
- Neurology referral: Done on 19/06/25
- Treatment: IV methylprednisolone for 3–5 days
- Ophthalmology: Referred on 23/06/25
→ impression: left temporal sectoral pallor
Diagnosis & Impression:
- Cerebellar ataxia suspected (possible causes: alcohol, drugs, hyperthyroidism, demyelination)
- Later confirmed hyperthyroidism due to overdosing
- No improvement with steroids
- Mild improvement with vitamin B12
- Financial constraints limited further testing (e.g., NCS)
Follow-up Plan:
- Continue Olanzapine titrated
- NCS studies and neurology follow-up
[24/06, 14:37]: - Ophthalmology OPD every 6 months for fundus exam
Discharge: In hemodynamically stable condition.
[24/06, 14:37]:
Investigations (as on 16/06/25):
- Hemogram:
- Hemoglobin: 14.4 g/dl
- Total WBC: 8500 cells/cu.mm
- Neutrophils: 53%, Lymphocytes: 40%, Eosinophils: 1%, Monocytes: 6%, Basophils: 0%
- RBC count: 4.89 million/cu.mm
- Platelets: 3.1 lakh/cu.mm (adequate)
- RBC morphology: Normocytic normochromic
- Impression: Normal blood picture
- Urine Examination:
- Colour: Pale yellow, Appearance: Clear
- Reaction: Acidic, Specific gravity: 1.010
- Sugar, bile salts, pigments, pus cells: Nil
- Epithelial cells: 2-3, RBCs: Nil, Crystals/Casts/Amorphous deposits: Absent
- Renal Function:
- Blood Urea: 21 mg/dl
- Creatinine: 0.8 mg/dl
- Electrolytes:
- Sodium: 136 mmol/L, Potassium: 3.8 mmol/L, Chloride: 101 mmol/L
- Infectious Disease Markers:
- HBsAg, HCV, HIV: Negative/Non-reactive
- Liver Function:
- Total Bilirubin: 0.64 mg/dl, Direct Bilirubin: 0.20 mg/dl
- SGOT (AST): 34 IU/L, SGPT (ALT): 33 IU/L
- ALP: 245 IU/L
- Total proteins: 7.5 gm/dl, Albumin: 4.5 gm/dl
- A/G ratio: 1.51
- Thyroid Profile:
- T3: 1.12 ng/ml, T4: 16.93 mcg/dl, TSH: 0.008 µIU/ml
- RBS (Random Blood Sugar): 108 mg/dl
---
Treatment Given:
[24/06, 14:37] : - Inj. Methylprednisolone 1g in 100 ml NS IV over 1 hr x 5 days
- Tab. Thyronorm 75 mcg PO/OD (1 hr before food)
- Tab. Olanzapine 2.5 mg PO/OD/HS
- Tab. Nervz-D PO/OD (0-1-0)
- Tab. MVT PO/OD/2PM (X-2PM-X)
Advice at Discharge:
- Continue Tab. Thyronorm 75 mcg OD
- Continue Tab. Olanzapine 2.5 mg OD
- Tab. Nervz-D OD for 14 days
- Eye OPD review every 6 months
- Neurology OPD follow-up on Thursday with NCS reports
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