Acute Disseminated

Encephalomyelitis
Source: Mother
% Reliability: 90%

Patient’s Profile:

D.S. is an 11-year old female, Roman Catholic, Filipino student living in San
Vicente, Liloan, Cebu and was admitted for the first time at the Cebu Velez
General Hospital last July 16, 2019 due to loss of vision in the right eye
Pre-natal:
Mother was 25 years old with an OB score of G 4 P 3 (2103) at the time of
pregnancy. First prenatal checkup was done at 4 months AOG conducted by an
obstetrician at Chong Hua Hospital. Mother was diagnosed with gestational
diabetes (highest recorded FBS = 150 mg/dL) and was managed with insulin with
unrecalled units, with which she took with good compliance. Subsequent prenatal
checkups were done regularly. She was prescribed with iron, folic acid, and
calcium supplements (dosage and frequency unrecalled), taken with good
compliance. Mother was non-hypertensive and had no other illnesses during
pregnancy. She is a non-smoker and non-alcoholic drinker. Blood type is A
positive.
Natal:
Patient was born a full term, live, female neonate with good cry and
spontaneous movements via normal spontaneous delivery, after 8 hours of labor
in CHH assisted by an obstetrician, BW = 2720 g. BCG vaccine, hepatitis B
vaccine, vitamin K, and Erythromycin eye ointment were administered at birth.
Patient was noted to be jaundiced after 24 hours of birth. Jaundice resolved with
phototherapy, and was discharged a week after. . No meconium staining, no cord
coil. Birth rank is 4/8.
Postnatal:
Patient’s newborn screening results were normal. Patient was exclusively
breastfed for 3 months; supplementary feeding with milk formula (dilution 1:1) was
started at 3 months old and given until 1 year of age; infant cereal was introduced
at 4 months. Mother claims complete immunization coverage for 1 year given by
their private pediatrician, exact immunizations unrecalled. Patient took
multivitamins and Vitamin C supplements daily
Developmental Milestones
● Smiles at 2 months
● Able to sit without support at 7 months
● Able to stand at approximately 7-8 months
● Scribble and wave goodbye at 10 months
● Respond to name at 11 months
● Walk without support, say first real word and 2-word sentences at 1 year
● Runs at 1 and ½ years
● Write the alphabet at 3 years
Personal-Social
Patient sleeps at least 9 hours per night. Water intake is approximately 6
glasses per day; urinates 3 times a day and defecates 3-4 times a week. No
previous hospitalizations. No history of childhood illnesses. No food and drug
allergies. Patient lives with 7 people at home, all of them apparently well. Primary
care provider is her mother. Food is usually prepared by the household helper.
Source of water is mineral water for drinking, and tap water for food preparation
and other purposes. Patient is currently a grade 5 student, and has always had
good school performance. She also interacts well among her peers.
Heredofamilial Diseases
Heredofamilial diseases include type 2 diabetes mellitus (mother), rheumatic
heart diseases (grandmother), and hypertension on the maternal side; father is
hypertensive. Siblings and other members of the family do not present with
neurologic deficits, similar symptoms or complaints with patient.
History of Present Illness

Problem: Unilateral loss of vision, right eye

Four days prior to admission, patient had productive cough and coryza with
clear and watery nasal secretions. No associated fever, headache, nausea or
vomiting. Patient tolerated symptoms, and no intervention was done.

Two days PTA, cough and coryza persisted, this time associated with fever of
undocumented temperature. She was given paracetamol (Calpol), dose
unrecalled, with partial relief.
 One day PTA, patient noted presence of black spots equally distributed on all
visual fields on her right eye which obscured her vision immediately upon waking
up. Symptoms persisted throughout the day, were tolerated and patient proceeded
with daily activities. On the afternoon of the same day, patient was noted to have
unusual gait, somewhat leaning towards her right and easily losing balance. There
was no associated headache, dizziness, nausea or fever. No history of trauma

.
 On the day of admission, patient had a complete loss of vision in her right eye,
not associated with pain or foreign body sensation. Gait continued to be unstable.
No changes in sensorium, no speech deficits, no dystaxia. Patient sought consult
from an optometrist and was referred to a neuro-ophthalmologist who advised
patient to undergo MRI and admission at CVGH.
Physical Examination
General Survey: Examined an awake, responsive, afebrile, patient not in
respiratory distress with the following vital signs:

BP: 90/60 mmHg

PR: 74 bpm
RR: 20 cpm
Temp: 36.9°C
Weight: 41kg
SKIN: Brown complexion, good mobility and turgor, no lesions

HEENT:

● Normocephalic head, well distributed thick wavy black hair, no deformities, nontender
● Symmetric eyes, no lesions, no discharges, white sclera, moist cornea, pink palpebral conjunctiva,
IOP firm by digital palpation, visual acuity and visual fields are intact on left eye, but (-) on the right
eye
● No nasal discharge, septum at midline
● Pink oral mucosa, no lesions, tongue at midline at rest and on protrusion

NECK: Supple, no lymphadenopathy, trachea at midline

CHEST & LUNGS: Symmetrical, equal chest expansion, equal tactile fremitus,
vesicular breath sounds over all lung fields, no adventitious breath sounds

CVS: Adynamic precordium, distinct S1 and S2, regular rhythm, normal heart rate
of 75 bpm, no murmurs

ABDOMEN: Flat, normoactive, no organomegaly

BACK: (-) Kidney punch sign

EXTREMITIES: Symmetrical, no deformities, no edema, CRT<2 seconds

GUT: Grossly female, pubic hair seen to be
lightly pigmented and straight.
Breast and papilla are elevated as small mound.
Sexual maturity rating of 2.
Neurologic Exam:

Cerebral: Coherent, able to solve simple math problems, oriented to time, and date, remembers name,
and recognizes family

Cranial Nerves:

● II&III: (+)PLR Left eye; (-)PLR right eye; (+)RAPD and (-) light perception right eye
● III, IV, & VI: Full ROM by finger following test
● V: (+)Corneal reflex; intact facial sensation; muscles of mastication strong
● VII: Symmetrical facial features
● VIII: Able to hear via whispered voice test
● IX&X: (+) gag reflex
● XI: Can shrug shoulders equally against resistance
● XII: Tongue at midline at rest and on protrusion
Motor: Good muscle tone; 5/5 muscle strength on all extremities; sudden involuntary shrugging of right
shoulder noted

Cerebellum: Able to perform finger-to-nose test, heel-to-shin test, and rapid alternating movements, but
unable to tandem walk

Sensory: Intact pain and light touch sensation

Reflexes:
Approach to unilateral vision loss in children
To achieve clear vision, light must follow an unhindered path from the front to the back of the eye, traveling through the cornea,
aqueous humor, lens, and vitreous humor to the retina. Refracted by the cornea and lens (and perhaps also by glasses or contact
lenses), light is focused onto the retina where it is transformed into an electrochemical signal by photoreceptors and supporting cells.
The signal is transmitted via the optic nerve through the visual pathways to the occipital lobes.
Alterations in function of any of the structures along the visual pathway may cause vision loss. Pathology can be broadly
divided into three major anatomic categories:
1. Visual media problems – Disorders of the cornea, anterior chamber, lens, and vitreous
2. Retinal problems – Vascular occlusion, retinal detachment, and retinal tumors
3. Neurovisual problems – Optic nerve, chiasmal, and retrochiasmal pathology
TO BE EDITED
Focusing on Neurovisual problems:
A detailed examination is critical to the accurate identification of an optic neuropathy or ocular disorder producing acute visual
loss. Reduced central visual acuity may occur with both optic nerve and ocular conditions, both of which must be considered when
acuity cannot be corrected by pinhole or refraction. Color vision (which can be assessed with pseudoisochromatic color plates or by
testing for perceived color desaturation) is often disproportionately affected by an optic neuropathy.
The hallmark of a unilateral optic neuropathy is the relative afferent pupillary defect (RAPD). The RAPD is determined by
the swinging flashlight test, during which light is alternately directed toward each pupil. When light is directed toward the unaffected
eye, both pupils should constrict normally. When light is shined into the affected eye, the dilation of both pupils indicates the presence
of a RAPD. In a more subtle RAPD, when the affected eye is stimulated the pupils may initially constrict but demonstrate a quicker
redilation. While a small RAPD may be observed in the setting of moderate or severe retinal dysfunction, it is often readily apparent
with even mild unilateral or asymmetric optic neuropathy.
The appearance of the retina and optic disc provides critical information regarding the likely cause of acute monocular visual
loss. A detailed retinal examination following pharmacologic pupillary dilation may reveal evidence of vitreous hemorrhage, retinal
arterial or venous infarction, retinal detachment, or other macular pathology. The optic nerve head should be assessed for signs of
swelling, pallor, or normal appearance. Optic disc swelling in a patient with acute monocular visual loss may indicate ischemia or
inflammation of the optic nerve head. A normal optic disc is expected with retrobulbar processes, such as typical optic neuritis.
Optic disc pallor would indicate chronic compression or prior optic nerve injury, but these are unlikely to present with acute visual loss
unless the patient had unrecognized subclinical injury. When the retina and optic disc appear normal in the setting of acute visual
loss, the identification of a retrobulbar optic neuropathy relies heavily on determining the presence of a RAPD.
MOST COMMON DISORDERS THAT PRESENT WITH UNILATERAL VISUAL LOSS

Laterality is crucial to localization: unilateral vision loss typically indicates a lesion

anterior to the chiasm, whereas bilateral vision loss may reflect a bilateral ocular,
chiasmal, or retrochiasmal process. Causes of childhood severe visual impairment
or blindness can further be classified as congenital, tumors, neurodegenerative
diseases, infectious or inflammatory processes, hematologic disorders, vascular
and circulatory disorders, trauma, drugs and toxins, and others. Common
disorders under these different categories include retinoblastoma, multiple
sclerosis, neuromyelitis optica, encephalitis, retinal occlusion, retinal detachment,
optic neuritis, etc.
A. OPTIC NEURITIS
B. MULTIPLE SCLEROSIS
C. NEUROMYELITIS OPTICA
D. RETINOBLASTOMA
E. RETINAL ARTERY OCCLUSION
F. AMAUROSIS
G. RETINAL DETACHMENT
CORRELATION:
Patient is an 11-year old female who presented with acute right unilateral vision loss. It started as black spots equally
distributed on all visual fields that progressed to complete loss of vision in her right eye within just twenty-four hours. Patient was
unable to read newsprint, unable to perform finger counting test, hand movement test and light perception thus patient was noted to
have relative afferent pupillary light defect. Four days prior to admission, patient had productive cough and coryza with clear, watery
nasal discharges. Another associated symptom was patient’s unstable gait which prompted her for assistance when she walks.
Clinical Formulation
Primary Differential 1: Differential 2: Differential 3:
Impression: Optic Multiple Sclerosis Neuromyelitis Central Nervous
Neuritis Optica System Infection

Epidemiology/ -¼ of all -older than 10 -Asian female -age

Predisposing Risk demyelinating -female preponderance -immune status
presentations in predominance -
childhood
-older than 10
years of age
-female
predominance
Clinical Formulation
Primary Differential 1: Differential 2: Differential 3:
Impression: Optic Multiple Sclerosis Neuromyelitis Central Nervous
Neuritis Optica (NMO) System Infection

Clinical -rapidly -visual and gait -visual loss Meningitic form:

Presentation developing disturbance (usually bilateral) -fever
impairment of -tendency to -limb weakness -headache
one or both eyes relapse -bladder -vomiting
-abnormal color -associated dysfunction -nuchal rigidity
vision symptoms:
-visual field loss specific signs of Encpehalitic form:
-relative afferent *facial weakness, NMO but absent in -altered LOC
pupillary defect *dysarthria the patient: -behavior disorders
-symptoms of *paresthesia -painful tonic -focal neurologic
preceding viral (absent in this spasm signs
infection case) -intractable -seizures
vomiting and
hiccups
-seizures,
somnolence
Clinical Formulation
Primary Differential 1: Differential 2: Differential 3:
Impression: Optic Multiple Sclerosis Neuromyelitis Central Nervous
Neuritis Optica System Infection

Pathophysiology - Idiopathic -immune-mediated -immune-mediated -infection caused

-demyelination and by bacteria,
Possible Possible axonal damage to viruses, fungi,
mechanisms: mechanisms: optic nerves and parasites
- Cross reaction of -Enhanced spinal cord -symptoms depend
viral and host expression of on organism and
epitopes adhesion -presence of anti- location affected
- Persistence of a molecules on AQP4 antibodies:
virus in the CNS lymphocytes and disease specific
glial cells macrophages
-Breakdown of
Blood-brain barrier
DISCUSSION ON LABS ORDERED
Diagnostic Tests
Definitive:

1. Brain MRI plain and with contrast

● To document presence of lesions, hemorrhage, or any other tissue
changes
1. Spinal MRI
● To detect lesions in the spinal cord
Diagnostic Tests
Supportive

1. Lumbar Puncture
○ For CSF analysis
2. Complete Blood Count
○ To document presence of systemic infection or hypersensitivity reactions
3. Urinalysis
○ To establish baseline values for further changes and therapeutic procedures
4. Chest X-ray
○ To document presence of respiratory tract infection
5. CRP
a. Used as an adjunct for presumptive determination of the etiologic
agent
6. ESR
a. Used as an adjunct to rule out other etiologic agents
7. Creatinine
a. To check for renal function as an aid in deciding the course of therapy
8. ANA Test
a. To exclude the presence of systemic autoimmune diseases
MRI RESULT
Interpretation
Axial T1, T2-weighted and FLAIR MRI sequences of the brain were performed with additional T2W sagittal and coronal sequences. Diffusion and susceptibility weighted images were also obtained.

There are multiple ill defined almost nodular lesions scattered throughout seen gray-white matter junction in both hemispheres including the parasagittal regions.

Despite the extent of the lesion there is no demonstrable significant mass effect.
There are no components of restricted diffusion or hemorrhage.

There is relative sparing of the deep nuclear and periventricular white matter regions. The brainstem and cerebellar regions are velar.

The ventricles are normal in size, symmetric without deformities or shifts.

The septum pellucidum is midline.

The peripheral sulci are intact.
The calvarium appears intact.

Images of the orbits reveal asymmetric appearance of the orbits with the right optic nerve larger than the left. The right optic nerve is further characterized by patchy T2 hyperintensity signals with
minimal surrounding fat stranding.

The left optic nerve is unremarkable.

Screening T2 sagittal images of the whole spine fail to demonstrate any suspicious abnormal intramedullary hyperintensity signals.

Impression:

Multifocal ill defined lesions involving the gray-white matter junction in both hemispheres including parasagittal regions with additional findings consistent with right optic neuritis.

The pattern of involvement of the lesions without significant mass effect suggest a demyelinating etiology. Acute Disseminated Encephalomyelitis (ADEM) is the primary consideration.

No demonstrable intramedullary abnormalities within the spinal cord to suggest transverse myelitis.
MRI:
LABORATORY RESULTS
Lumbar Puncture Gross: Colorless, CLear
Cell count:
RBC: 18 cells/cu. mm.
WBC: 5 cells/cu. mm.
Differential count: Not done due to low WBC
count.

CBC WBC: 7.45

Plt: 314
Hct: 44.9
Hgb: 14.1
N: 59.8
L: 29.5
M: 7.7
E: 2.33
B: 0.684

Urinalysis Unremarkable

Chest Xray Unremarkable

CRP 1.77 mg/dl (N: 0-5.0)

ESR 34 mm (N: 0-10)

Creatinine 0.6 mg/dl (N: 0.6-1.5)

ANA Test NEGATIVE

WORKING IMPRESSION
Acute Disseminated Encephalomyelitis
Acute Disseminated Encephalomyelitis
DISCUSSION
Distinguishing ADEM and Multiple Sclerosis
ADEM MULTIPLE SCLEROSIS
Therapeutics
Definitive:

1. Methylprednisone IV 900mgD (AD = 30mg/kg/d)

- An anti-inflammatory and immunosuppresive agent, which is considered the mainstay of ADEM treatment. The presumed
autoimmune etiopathogenesis is taken into account for resolution of visual and neurologic deficits.

Supportive:

1. D5LR at 80cc/hr

- Maintenance therapy to ensure adequate hydration

2. Cefuroxime IV 750mg q8hrs

3. Fall precaution

4. Strict handwashing at all times, limit visitors, and wear mask at all times upon
entering patient’s room
Course in the ward
Day 1 (July 17, 2019)
S: Patient has no subjective complaints apart from the fact that she cant see using
her right eye. Patient is not dizzy, no vomiting, able to maintain balance while
walking. No fever, no headache.

O: Seen patient awake, cooperative, afebrile, not in respiratory distress with the
following vital signs:
PR: 90bpm RR: 26cpm Temp: 36.2C
Skin: Good turgor & mobility, no rashes, no lesions.
HEENT: Normocephalic, anicteric sclera, no alar flaring.
C/L: Clear breath sounds, equal chest expansion, no adventitious breath sounds
CVS: Distinct heart sounds
Abdomen: no tenderness on light and deep palpation
GUT: (-)KPS, both sides.
Extremities: CRT<2 secs
CNS:
Cerebral: Coherent; oriented to time, place, and person
Cranial nerves:
CN 1: intact
CN 2, 3: (+) PLR EBRTL on left eye, (-) ln right eye; (+) RAPD on right eye; (-)
light perception on right eye
CN 3, 4, 6: full range EOM.
CN 5: (+) corneal reflex, intact facial sensations
CN 7: symmetrical facial expressions
CN 8: intact
CN 9, 10: able to swallow
CN 11: able to shrug shoulders equally against resistance
CN 12: tongue midline upon protrusion
Cerebellar: able to perform finger to nose test
Sensory: intact on both sides
Motor: 5/5 on all extremities

A: Optic neuritis of the right eye

P: 1. Cranial MRI
2. Fall precaution
3. Steroids
Day 2 (July 18, 2019)

S: Patient started coughing w/c was non-productive. No other subjective

complaints. Afebrile for the past 24 hours w/ good appetite and adequate urine
output & bowel movement. Patient was sent to another hospital for MRI.
O: Seen patient awake, cooperative, afebrile, not in respiratory distress with the
following vital signs: PR: 62 RR: 21 T: 36.3
Skin: Good turgor & mobility, no rashes nor lesions.
HEENT: Normocephalic, anicteric sclera, no alar flaring
C/L: Clear breath sounds, equal chest expansion. (-) adventitious sounds
Day 2 (July 18, 2019)

CVS: Distinct heart sounds

Abdomen: (-) tenderness
GUT: (-) KPS bilaterally
Extremities: CRT < 2 secs
CNS: Cerebral: coherent, oriented to time, place and person
CN: I: intact
II, III: (+)PLR EBRTL on L eye, (-) on R eye; (+) RAPD on R eye;
(-) Light perception on R eye
III, IV, VI: full range EOM
Day 2 (July 18, 2019)

V: (+) corneal reflex, intact facial sensations

VII: symmetrical facial expressions

VIII: intact

IX, X: able to swallow

XI: able to shrug shoulders equally against resistance

XII: tongue midline upon protrusion

Cerebellar: able to perform finger to nose test, unable to maintain balance

Sensory: intact on both sides Motor: 5/5 on all

Day 2 (July 18, 2019)
Laboratory Results:
July 16, 2019
Creatinine: 0.6 mg/dl CRP: 1.77 mg/dl Chest X-ray:
Unremarkable
CBC: Hgb: 14.1 Hct: 44.9 WBC: 7.45
Differential count: N: 59.8; L: 29.5; M: 7.7; E: 2.33; B: 0.684
MRI:
A: Acute Disseminated Encephalomyelitis

P: 1. Start medications: Cefuroxime: 750 mg q8hrs IVTT

Methylprednisolone 1 g/day

2. Monitor while on methylprednisolone, q15 got first, q30 after

3. Monitor V/S

4. Check for neurological changes

Day 3 (July 19, 2019)
S: Patient complained of squeezing pain on her left lumbar area yesterday. Patient
screamed in pain then was given an analgesic. Patient had no episode of vomiting
but sometimes complained of nausea. Patient did not have a febrile episode. No
complaint of headache, no changes in sensorium. No other subjective complaints.

O: Seen patient asleep, afebrile, no alar flaring, not in respiratory distress w/the
following vital signs:

PR: 78bpm RR: 24cpm Temp: 36.5°C

Day 3 (July 19, 2019)
Skin: good turgor & mobility, no lesions

HEENT: anicteric sclerae, no nasolacrimal discharges, no alar flaring

C/L: clear breath sounds, equal chest expansion, (-) rales/wheezes

CVS: adynamic precordium, distinct heart sounds

Abdomen: protuberant (-) tenderness

GUT: (-) KPS bilaterally

Extremities: CRT < 2 secs, strong pulses

Day 3 (July 19, 2019)
CNS:

Cerebral: coherent, oriented to time, place and person

Cranial Nerves:

CN I: intact

CN II, III: (+)PLR EBRTL on L eye, (-) on R eye; (+) RAPD on R eye

CN III, IV, VI: full range EOM

CN V: (+) corneal reflex, intact facial sensations

Day 3 (July 19, 2019)
CN VII: symmetrical facial expressions

CN VIII: intact

CN IX, X: able to swallow

CN XI: able to shrug shoulders equally against resistance

CN XII: tongue at midline upon protrusion

Cerebellar: able to perform finger to nose test

Sensory: intact on both sides

Day 3 (July 19, 2019)
Motor: 5/5 on all

A: ADEM

P: - Continue medications

- Please monitor patient for any signs of neurological

changes/deterioration
- Monitor v/s q2 hours
- Refer accordingly
Day 4 (July 20, 2019)

S: Patient complained of squeezing pain on her left lumbar area yesterday. Patient
screamed in pain then was given an analgesic. Patient had no episode of vomiting
but sometimes complained of nausea. Patient did not have a febrile episode. No
complaint of headache, no changes in sensorium. No other subjective complaints.
Day 4 (July 20, 2019)
O: Seen patient asleep, afebrile, no alar flaring, not in respiratory distress

Vital signs: PR: 78 RR: 24 Temp: 36.5

​Skin: good turgor & mobility, no lesions

​HEENT: anicteric sclerae, no nasolacrimal discharges, no alar flaring

​C/L: clear breath sounds, equal chest expansion, (-) rales/wheezes

​CVS: adynamic precordium, distinct heart sounds

Abdomen: protuberant (-) tenderness

​GUT: (-) KPS bilaterally

Day 4 (July 20, 2019)
​Extremities: CRT < 2 secs, strong pulses

​CNS:​Cerebral: coherent, oriented to time, place and person

​CN:​I: intact

​II, III: (+)PLR EBRTL on L eye, (-) on R eye; (+) RAPD on R eye

​III, IV, VI: full range EOM

​V: (+) corneal reflex, intact facial sensations

​VII: symmetrical facial expressions

Day 4 (July 20, 2019)

VIII: intact

IX, X: able to swallow

​XI: able to shrug shoulders equally against resistance

​XII: tongue at midline upon protrusion

​Cerebellar: able to perform finger to nose test

​Sensory: intact on both sides

​Motor: 5/5 on all

Day 4 (July 20, 2019)

A: ADEM

P: - Continue medications

- Please monitor patient for any signs of neurological changes/deterioration

- Monitor v/s q2 hours

- Refer accordingly
Day 5 (July 21, 2019)
S: Patient has no subjective complaints. Patient is able to see light with her right
eye. Patient is afebrile for the past 24 hours. No vomiting, no dizziness, no
headache. Patient has adequate urine output and appetite is good. Patient walks
with assistance without dizziness.

O: Seen patient wake, oriented, cooperative and responsive to questions, not in

respiratorydistress with the following vital signs:

PR: 78bpm RR: 22cpm Temp: 36.0

Day 5 (July 21, 2019)
Skin: good turgor and mobility, no rash, no edema

HEENT: anicteric sclerae, no nasolacrimal discharges, no alar flaring, tonsils not

inflamed

C/L: equal chest expansion, (+) rhonchi on L lower lung field, (+) chest tightness
on R lung field, (+) adventitious sounds

CVS: adynamic precordium, distinct heart sounds

Abdomen: nbs, (-) tenderness

GUT: (-) KPS bilaterally

Extremities: CRT <2 sec, strong peripheral pulses

Day 5 (July 21, 2019)
CNS: Cerebral: coherent, oriented to time, place and person
CN: I: intact
II, III: (+)PLR EBRTL on L eye, (-) on R eye;
III, IV, VI: full range EOM
V: (+) corneal reflex, intact facial sensations
VII: facial asymmetry
VIII: intact
IX, X: able to swallow
XI: able to shrug shoulders equally against resistance
XII: tongue at midline upon protrusion

Cerebellar: able to perform finger to nose test, walks assisted with no imbalance
Sensory-intact
Motor: 5/5 on all extremities
Day 5 (July 21, 2019)
A: Acute Disseminated Encephalomyelitis

P: Continuous medications:

1.) Patient is on her 4th day of Cefuroxime

2.) Melthylprednisone- 4th day

3.) Ibuprofen 200mg/tab- ….. for pain

: Monitor and refer accordingly

Day 6 (07/22/2019)
S: Patient’s coughing episodes diminished as claimed by the mother. Patient has
been afebrile for the past 24 hours. No vomiting, no complaints of dizziness. Right
eye vision still impaired with only light can be percepted. No other subjective
complaints.

O: seen patient awake; afebrile, coherent, not in respiratory distress with the
following vital signs:

PR= 74 bpm; RR= 20 cpm; Temp=36.4

Skin: good turgor and mobility, no rash/lesions

Day 6 (07/22/2019)
HEENT: anicteric sclerae, no nasolacrimal discharges, no alar flaring, tonsils not

inflamed, not enlarged

Neck:(-) lymphadenopathies

C/L: equal chest expansion, clear breath sounds, (-) tight

airways, (-) crackles

CVS: adynamic precordium, distinct heart sounds

Abdomen: NABS, (-) tenderness

Day 6 (07/22/2019)

Extremities: CRT < 2s, strong peripheral pulses

CNS: Cerebral: coherent, oriented to time, place and person

CN I: intact

CN II, III: (+)PLR EBRTL on L eye, (-) on R eye; (+) light perception at right eye

CN ​III, IV, VI: full range EOM

CN ​V: (+) corneal reflex, intact facial sensations

CN ​VII: facial asymmetry

Day 6 (07/22/2019)
CN ​VIII: intact

CN ​IX, X: able to swallow

CN ​XI: able to shrug shoulders equally against resistance

CN ​XII: tongue at midline upon protrusion

​Cerebellar: able to tandem walk, well coordinated movements by finger to nose

test and heel to shin test

Sensory: intact on both sides

​Motor: 5/5 on all extremities

Day 6 (07/22/2019)
A: ADEM

P: continue medications; patient has completed methylprednisolone treatment

> start Pregabalin 50 mg/cap, 1 cap twice a day

> please monitor V/S

> refer if with new onset of neurological problems

Day 7 July 23, 2019
S > Patient has no febrile episodes. No new subjective complaints. Patient was
able to do heel to toe walking with slight difficulty. No dizziness, no vomiting, no
headache. No changes in vision of the right eye. Patient’s vital signs stable with
no motor weakness/deficit.

O > seen patient asleep, afebrile, not in respiratory distress with the following vital
signs:

PR: 70 bpm ; RR: 18 cpm ; Temp: 36.5 C

Day 7 July 23, 2019
Skin – Good turgor and mobility, no edema, no rash/lesions

HEENT – anicteric sclerae, no nasolacrimal discharges, (-) alar flaring, tonsils not
inflamed

NECK – No lymphadenopathy

C/L – equal chest expansion, clear breath sounds, negative rales/crackles

CVS – distinct heart sounds

Abdomen – negative tenderness

Day 7 July 23, 2019
GUT – negative KPS bilaterally

Extremities – CRT < 2 seconds, strong peripheral pulses

CNS: Cerebral: coherent, oriented to time, place and person

CN: I: intact

II, III: (+)PLR EBRTL on L eye, (-) on R eye; (+) light perception at right eye

III, IV, VI: full range EOM

V: (+) corneal reflex, intact facial sensations

Day 7 July 23, 2019
VII: facial asymmetry

VIII: intact

IX, X: able to swallow

XI: able to shrug shoulders equally against resistance

XII: tongue at midline upon protrusion

Cerebellar: able to tandem walk, well coordinated movements by finger to nose

test and heel to shin test
Day 7 July 23, 2019
Sensory: intact on both sides

Motor: 5/5 on all

A – ADEM

P > Patient completed IV Methylprednisolone and switched to Prednisone

20mg/tab 1 1/2 tab PO breakfast and 1 tab PO dinner

➢ Complete Cefuroxime 75 mg q 8 hours IVTT – last dose today

➢ Refer accordingly for changes sensorium / vision

Day 8 (July 24, 2019)
S: Patient eats and sleeps well. Patient’s mother claims that patient can now
perceive shadows on her R eye. Patient still requires assistance when walking to
the toilet. No problems in voiding. Patient has no subjective complaints. No febrile
episodes, no headache, no dizziness, no vomiting.

O: Patient seen asleep, afebrile, not in respiratory distress with the following vital
signs:

T: 36.6 C PR: 78bpm RR: 22 cpm

Skin: good turgor and mobility

Day 8 (July 24, 2019)
HEENT: anicteric sclerae, no nasolacrimal discharges, no alar flaring, tonsils not
inflamed Chest & Lungs: equal chest expansion, clear breath sounds,

CVS: distinct S1 & S2, no murmurs

Abdomen: (-) tenderness

Extremities: CRT <2 secs, strong peripheral pulses

CNS: Cerebral: coherent, oriented to time, place and person

Day 8 (July 24, 2019)
CN:

I: intact

II, III: (+)PLR EBRTL on L eye, (-) on R eye;

(+) light perception at right eye

III, IV, VI: full range EOM

V: (+) corneal reflex, intact facial sensations VII: facial asymmetry

VIII: intact
Day 8 (July 24, 2019)
IX, X: able to swallow

XI: able to shrug shoulders equally against resistance

XII: tongue at midline upon protrusion

Cerebellar: able to tandem walk, well coordinated movements by finger to nose

test and heel to shin test Sensory: intact on both sides

Motor: 5/5 on all

Day 8 (July 24, 2019)
A: ADEM

P: Patient is on her last day of IV antibiotics

> Oral prednisone 20 mg/tab 1 1⁄2 tablet after breakfast and dinner was started

> Advised mother about susceptibility of patient to diseases due to steroid therapy
> Patient is stable and may be discharged today
TREATMENT FOR ADEM
DISCUSSION ON IMPROVEMENT OF
VISION
PROGNOSIS