Case 1 .75 female with altered sensorium

Diagnosis

ALTERED SENSORIUM SECONDARY TO ?HYPOGLYCEMIC SEIZURES WITH ASPIRATION

PNEUMONIA ? HYPOXIC ENCEPHALOPATHY

?NON CONVULSIVE STATUS EPILEPTICUS

K/C/O TYPE II DIABETES MELLITUS

K/c/O HTN

ACUTE CHOLECYSTITIS AND DIABETIC KETOACIDOSIS 1 MONTH AGO

Case History and Clinical Findings

PATIENT PRESENTED TO CASUALTY ON 13-11-24 IN UNRESPONSIVE STATE ATTENDERS

NOTICED PATIENT BEING APPARENTLY ALRIGHT AT 2:30 AM .AT 8 AM THEY NOTICED THAT

PATIENT IS UNRESPONSIVE AND HAVE BROUGHT HER TO HOSPITAL

NO H/O FROATHING FROM MOUTH ,INVOLUNTARY MICTURATION OR DEFECATION OR

INVOLUNTARY MOVEMENTS

NO H/O SIMILAR COMPLAINTS IN THE PAST

NO H/O FEVER VOMITINGS, LOOSE STOOLS ,SOB,COUGH ,CHEST PAIN ,PEDAL ODEMA

,DECREASED URINE OUTPUT

PAST HISTORY;

K/C/O DM TYPE II PATIENT IS ON MIXTARD 160 MG PO/BDT.ISTAMET 50/500 MG PO/OD

K/C/O ACUTE CHOLECYSTITIS (RESOLVED)

N/K/C/O CVA ,TB , EPILEPSY , ASTHMA, CAD, THYRIOD DISORDER

PERSONAL HISTORY

APPETITE NORMAL

SLEEP ADEQUATE

BOWEL MOVEMENTS REGULAR

BLADDER MOVEMENTS REGULAR

FAMILY HISTORY NOT SIGNIFICANT

GENERAL EXAMINATION

NO PALLOR ICTERUS CYANOSIS CLUBBINGLYMADENOPATHY PEDAL EDEMA

VITALS

TEMPERATURE 98F

BP-NON RECORDABLE -->130/80MMHG

PR-FEEBLE --> 111PM

RR 20CPM

SPO2 96%AT RA

GRBS 271 MG%

SYSTEMIC EXAMINATION

CNS

POWER COULDNT BE ELICITED

TONE HYPOTONIA IN RIGHT UPPER LIMB

INCREASED TONE IN LEFT UPPER LIMB

BOTH LOWER LIMBS ARE NORMAL

B/L PUPILS NORMAL IN SIZE REACTIVE TO LIGHT

GLASGOW SCALE E2V2M3

REFLEXES RIGHT LEFT

BICEPS +2 +2

TRICEPS +2 +2

SUPINATOR +2 +2

KNEE - -

ANKLE +2 +2

PLANTAR EXTENSION MUTE

N/K/C/O HTN ,CVA ,TB , EPILEPSY , ASTHMA, CAD, THYRIOD DISORDER

PERSONAL HISTORY

APPETITE NORMAL

SLEEP ADEQUATE

BOWEL MOVEMENTS REGULAR

BLADDER MOVEMENTS REGULAR

FAMILY HISTORY NOT SIGNIFICANT

GENERAL EXAMINATION

NO PALLOR ICTERUS CYANOSIS CLUBBINGLYMADENOPATHY PEDAL EDEMA

VITALS

TEMPERATURE 98F

BP-NON RECORDABLE -->130/80MMHG

PR-FEEBLE --> 111PM

RR 20CPM

SPO2 96%AT RA

GRBS 271 MG%

SYSTEMIC EXAMINATION

CNS

POWER COULDNT BE ELICITED

TONE HYPOTONIA IN RIGHT UPPER LIMB

INCREASED TONE IN LEFT UPPER LIMB

BOTH LOWER LIMBS ARE NORMAL

B/L PUPILS NORMAL IN SIZE REACTIVE TO LIGHT

GLASGOW SCALE E2V2M3

REFLEXES RIGHT LEFT

BICEPS +2 +2

TRICEPS +2 +2

SUPINATOR +2 +2

KNEE - -

ANKLE +2 +2

PLANTAR EXTENSION MUTE

OTHER CRANIAL NERVES COULDNT BE ELICITED

CVS S1S2 HEARD NO MURMURS

PA SOFT NT

RS-B/L DIFFUSE GRUNTING SOUNDS HEARD

Investigation

HEMOGRAM 13-11-24HAEMOGLOBIN 9.8gm/dlTOTAL COUNT 15,300cells/cummNEUTROPHILS

82PCV 27.5vol %M C V 86.2flM C H 30.7pgRBC COUNT 3.19millions/cummPLATELET COUNT

2.69 lakhs/cu.mmSMEARRBCNormocytic normochromicWBCWith in normal

limitsPLATELETSAdeqauteHEMOPARASITES No hemoparasites seenIMPRESSIONNormocytic

normochromic Anemia

FBS- 200

PLBS- 348

HBa1C- 9

HBsAg-RAPID 13-11-2024 02:15:PM Negative

Anti HCV Antibodies - RAPID 13-11-2024 02:15:PM Non ReactiveCOMPLETE URINE

EXAMINATION (CUE) 13-11-2024 02:15:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR +BILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-

6EPITHELIAL CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS Nil

RFT 13-11-2024 02:15:PMUREA 35 mg/dl CREATININE 1.0 mg/dl URIC ACID 3.2 mmol/LCALCIUM

9.4 mg/dlPHOSPHOROUS 5.1 mg/dlSODIUM 138 mmol/LPOTASSIUM 4.0 mmol/L. CHLORIDE 101

mmol/L

LIVER FUNCTION TEST (LFT) 13-11-2024 02:15:PMTotal Bilurubin 2.10 mg/dl Direct Bilurubin 0.52

mg/dl SGOT(AST) 30 IU/L SGPT(ALT) 20 IU/L ALKALINE PHOSPHATASE 140 IU/L TOTAL

PROTEINS 5.9 gm/dl ALBUMIN 3.2 gm/dl A/G RATIO 1.21

ABG 14-11-2024 10:20:AMPH 7.39PCO2 33.2PO2 51.7HCO3 19.8St.HCO3 20.9BEB -3.9BEecf -

4.2TCO2 41.4O2 Sat 83.0O2 Count 11.8SERUM ELECTROLYTES (Na, K, C l) 14-11-2024

11:17:PMSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.7 mmol/L 5.1-3.5 mmol/LCHLORIDE

99 mmol/L 98-107 mmol/L

ABG 14-11-2024 11:17:PMPH 7.39PCO2 35.5PO2 76.3HCO3 21.4St.HCO3 22.3BEB -2.4BEecf -

2.7TCO2 43.4O2 Sat 94.8O2 Count 15.8

HEMOGRAM 15-11-24HAEMOGLOBIN 9.9gm/dlTOTAL COUNT 11,800cells/cummNEUTROPHILS

79PCV 29.3vol %M C V 88.5flM C H 29.5pgRBC COUNT 3.31millions/cummPLATELET COUNT

3.19lakhs/cu.mmSMEARRBCNormocytic normochromicWBCWith in normal

limitsPLATELETSAdeqauteHEMOPARASITES No hemoparasites seenIMPRESSION

Normocytic normochromic Anemia

MRI BRAIN

CHRONIC LACUNAR INFRACTS IN RIGHT THALAMUS AND LEFT CAUDATE NUCLEUS

FEW TINY CHRONIC INFRACTS IN RIGHT CEREBELLAR HEMISPHERE

SUBTLE PYRIFORM DIFFUSE RESTRICTION IN B/L PERIROLANDIC REGION

MULTIPLE DISCRETE AND CONFLUENT FLAIR HYPERINTENSITIES WITHOUT DIFFUSION

RESTRICTION IN B/L FRONTAL ,PARIETAL, PERIVENTRICULAR DEEP WHITE MATTER

ISCHEMIA

MILD DIFFUSE CEREBAL ATROPHY WITH PROMINENT SUPRATENTORIAL VENTRICULAR

SYSTEM.

2D ECHO:

TACHYCARDIA ON SUDY

NO RWMA, MILD LVH +

MODERATE MR+

MILD AR+

MODERATE TR WITH PAH

SCLEROTIC AV, NO AS/MS IAS-INTACT

EF-60%, GOOD LV SYSTOLIC FUNCTION

GRADE 1 DIASTOLIC DYSFUNCTION

IVC(0.8 CMS) COLLAPSING

NO PE/LV CLOT

LA SIZE(3.9 CMS)

USG ABDOMEN AND PELVIS:

RIGHT KIDNEY: 8.6X3.9 CMS

LEFT KIDNEY:9.1X4.0CMS

IMPRESSION: NO SONOLOGICAL ABNORMALITIES DETECTED

Treatment Given(Enter only Generic Name)

INJ.LEVIPIL 1GM IV STAT FOLLOWED BY

INJ LEVIPIL 500 MG IV/BD

INJ SODIUM VALPROATE 500 MG IV/BD

INJ PIPTAZ 4.5 GM IV/QID GIVEN FOR 3 DAYS

INIJ.CLINDAMYCIN 600 ML IV /TID GIVEN FOR 3 DAYS

IVF NS /RL @ 75 ML /HR

INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD

INJ NEOMOL 1 GM IV /SOS IF TEMP >100 F

INJ HAI SC/TID ACC TO GRBS

TAB PCM 650 MG RT /QID

TAB ECOSPRIN AV 7/10 RT HS

TAB STROCIT PLUS RT BD

NEB MUCOMIST 4TH HRLY

NEB IPRAVENT 4TH HRLY ,BUDECORT 8TH HRLY

RT FEEDS 100 ML MILD 4TH HRLY ,50 ML MILK 2 ND HRLY

Follow up on 15/1/25

FBS 140 PLBS 180 HBA1C 6.2

second followup on 19/2/25

HOME DEATH

@⁨Meta AI⁩

Coding: identify initial codes and labels to capture the key concepts and ideas.

Categorization: group the codes into categories and subcategories to organize the data.

Theme identification: identify the emerging themes and patterns in the data.

Theme representation: present the themes as learning points, highlighting the key findings and insights related to To estimate the variability in Clinical, Radiological and Laboratory, therapeutic factors in the spectrum of portal hypertension patients presenting to medicine department and

To assess spectrum of clinical presentations in diabetics with multimorbidities and factors influencing their outcome

And @⁨Meta AI⁩ let us know new insights about the topic and case rather than what we already know

Diagnosis

ALTERED SENSORIUM SECONDARY TO ?HYPOGLYCEMIC SEIZURES WITH ASPIRATION

PNEUMONIA ? HYPOXIC ENCEPHALOPATHY

?NON CONVULSIVE STATUS EPILEPTICUS

K/C/O TYPE II DIABETES MELLITUS

K/c/O HTN

ACUTE CHOLECYSTITIS AND DIABETIC KETOACIDOSIS 1 MONTH AGO

Case History and Clinical Findings

PATIENT PRESENTED TO CASUALTY ON 13-11-24 IN UNRESPONSIVE STATE ATTENDERS

NOTICED PATIENT BEING APPARENTLY ALRIGHT AT 2:30 AM .AT 8 AM THEY NOTICED THAT

PATIENT IS UNRESPONSIVE AND HAVE BROUGHT HER TO HOSPITAL

NO H/O FROATHING FROM MOUTH ,INVOLUNTARY MICTURATION OR DEFECATION OR

INVOLUNTARY MOVEMENTS

NO H/O SIMILAR COMPLAINTS IN THE PAST

NO H/O FEVER VOMITINGS, LOOSE STOOLS ,SOB,COUGH ,CHEST PAIN ,PEDAL ODEMA

,DECREASED URINE OUTPUT

PAST HISTORY;

K/C/O DM TYPE II PATIENT IS ON MIXTARD 160 MG PO/BDT.ISTAMET 50/500 MG PO/OD

K/C/O ACUTE CHOLECYSTITIS (RESOLVED)

N/K/C/O CVA ,TB , EPILEPSY , ASTHMA, CAD, THYRIOD DISORDER

PERSONAL HISTORY

APPETITE NORMAL

SLEEP ADEQUATE

BOWEL MOVEMENTS REGULAR

BLADDER MOVEMENTS REGULAR

FAMILY HISTORY NOT SIGNIFICANT

GENERAL EXAMINATION

NO PALLOR ICTERUS CYANOSIS CLUBBINGLYMADENOPATHY PEDAL EDEMA

VITALS

TEMPERATURE 98F

BP-NON RECORDABLE -->130/80MMHG

PR-FEEBLE --> 111PM

RR 20CPM

SPO2 96%AT RA

GRBS 271 MG%

SYSTEMIC EXAMINATION

CNS

POWER COULDNT BE ELICITED

TONE HYPOTONIA IN RIGHT UPPER LIMB

INCREASED TONE IN LEFT UPPER LIMB

BOTH LOWER LIMBS ARE NORMAL

B/L PUPILS NORMAL IN SIZE REACTIVE TO LIGHT

GLASGOW SCALE E2V2M3

REFLEXES RIGHT LEFT

BICEPS +2 +2

TRICEPS +2 +2

SUPINATOR +2 +2

KNEE - -

ANKLE +2 +2

PLANTAR EXTENSION MUTE

N/K/C/O HTN ,CVA ,TB , EPILEPSY , ASTHMA, CAD, THYRIOD DISORDER

PERSONAL HISTORY

APPETITE NORMAL

SLEEP ADEQUATE

BOWEL MOVEMENTS REGULAR

BLADDER MOVEMENTS REGULAR

FAMILY HISTORY NOT SIGNIFICANT

GENERAL EXAMINATION

NO PALLOR ICTERUS CYANOSIS CLUBBINGLYMADENOPATHY PEDAL EDEMA

VITALS

TEMPERATURE 98F

BP-NON RECORDABLE -->130/80MMHG

PR-FEEBLE --> 111PM

RR 20CPM

SPO2 96%AT RA

GRBS 271 MG%

SYSTEMIC EXAMINATION

CNS

POWER COULDNT BE ELICITED

TONE HYPOTONIA IN RIGHT UPPER LIMB

INCREASED TONE IN LEFT UPPER LIMB

BOTH LOWER LIMBS ARE NORMAL

B/L PUPILS NORMAL IN SIZE REACTIVE TO LIGHT

GLASGOW SCALE E2V2M3

REFLEXES RIGHT LEFT

BICEPS +2 +2

TRICEPS +2 +2

SUPINATOR +2 +2

KNEE - -

ANKLE +2 +2

PLANTAR EXTENSION MUTE

OTHER CRANIAL NERVES COULDNT BE ELICITED

CVS S1S2 HEARD NO MURMURS

PA SOFT NT

RS-B/L DIFFUSE GRUNTING SOUNDS HEARD

Investigation

HEMOGRAM 13-11-24HAEMOGLOBIN 9.8gm/dlTOTAL COUNT 15,300cells/cummNEUTROPHILS

82PCV 27.5vol %M C V 86.2flM C H 30.7pgRBC COUNT 3.19millions/cummPLATELET COUNT

2.69 lakhs/cu.mmSMEARRBCNormocytic normochromicWBCWith in normal

limitsPLATELETSAdeqauteHEMOPARASITES No hemoparasites seenIMPRESSIONNormocytic

normochromic Anemia

FBS- 200

PLBS- 348

HBa1C- 9

HBsAg-RAPID 13-11-2024 02:15:PM Negative

Anti HCV Antibodies - RAPID 13-11-2024 02:15:PM Non ReactiveCOMPLETE URINE

EXAMINATION (CUE) 13-11-2024 02:15:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR +BILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-

6EPITHELIAL CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS Nil

RFT 13-11-2024 02:15:PMUREA 35 mg/dl CREATININE 1.0 mg/dl URIC ACID 3.2 mmol/LCALCIUM

9.4 mg/dlPHOSPHOROUS 5.1 mg/dlSODIUM 138 mmol/LPOTASSIUM 4.0 mmol/L. CHLORIDE 101

mmol/L

LIVER FUNCTION TEST (LFT) 13-11-2024 02:15:PMTotal Bilurubin 2.10 mg/dl Direct Bilurubin 0.52

mg/dl SGOT(AST) 30 IU/L SGPT(ALT) 20 IU/L ALKALINE PHOSPHATASE 140 IU/L TOTAL

PROTEINS 5.9 gm/dl ALBUMIN 3.2 gm/dl A/G RATIO 1.21

ABG 14-11-2024 10:20:AMPH 7.39PCO2 33.2PO2 51.7HCO3 19.8St.HCO3 20.9BEB -3.9BEecf -

4.2TCO2 41.4O2 Sat 83.0O2 Count 11.8SERUM ELECTROLYTES (Na, K, C l) 14-11-2024

11:17:PMSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.7 mmol/L 5.1-3.5 mmol/LCHLORIDE

99 mmol/L 98-107 mmol/L

ABG 14-11-2024 11:17:PMPH 7.39PCO2 35.5PO2 76.3HCO3 21.4St.HCO3 22.3BEB -2.4BEecf -

2.7TCO2 43.4O2 Sat 94.8O2 Count 15.8

HEMOGRAM 15-11-24HAEMOGLOBIN 9.9gm/dlTOTAL COUNT 11,800cells/cummNEUTROPHILS

79PCV 29.3vol %M C V 88.5flM C H 29.5pgRBC COUNT 3.31millions/cummPLATELET COUNT

3.19lakhs/cu.mmSMEARRBCNormocytic normochromicWBCWith in normal

limitsPLATELETSAdeqauteHEMOPARASITES No hemoparasites seenIMPRESSION

Normocytic normochromic Anemia

MRI BRAIN

CHRONIC LACUNAR INFRACTS IN RIGHT THALAMUS AND LEFT CAUDATE NUCLEUS

FEW TINY CHRONIC INFRACTS IN RIGHT CEREBELLAR HEMISPHERE

SUBTLE PYRIFORM DIFFUSE RESTRICTION IN B/L PERIROLANDIC REGION

MULTIPLE DISCRETE AND CONFLUENT FLAIR HYPERINTENSITIES WITHOUT DIFFUSION

RESTRICTION IN B/L FRONTAL ,PARIETAL, PERIVENTRICULAR DEEP WHITE MATTER

ISCHEMIA

MILD DIFFUSE CEREBAL ATROPHY WITH PROMINENT SUPRATENTORIAL VENTRICULAR

SYSTEM.

2D ECHO:

TACHYCARDIA ON SUDY

NO RWMA, MILD LVH +

MODERATE MR+

MILD AR+

MODERATE TR WITH PAH

SCLEROTIC AV, NO AS/MS IAS-INTACT

EF-60%, GOOD LV SYSTOLIC FUNCTION

GRADE 1 DIASTOLIC DYSFUNCTION

IVC(0.8 CMS) COLLAPSING

NO PE/LV CLOT

LA SIZE(3.9 CMS)

USG ABDOMEN AND PELVIS:

RIGHT KIDNEY: 8.6X3.9 CMS

LEFT KIDNEY:9.1X4.0CMS

IMPRESSION: NO SONOLOGICAL ABNORMALITIES DETECTED

Treatment Given(Enter only Generic Name)

INJ.LEVIPIL 1GM IV STAT FOLLOWED BY

INJ LEVIPIL 500 MG IV/BD

INJ SODIUM VALPROATE 500 MG IV/BD

INJ PIPTAZ 4.5 GM IV/QID GIVEN FOR 3 DAYS

INIJ.CLINDAMYCIN 600 ML IV /TID GIVEN FOR 3 DAYS

IVF NS /RL @ 75 ML /HR

INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD

INJ NEOMOL 1 GM IV /SOS IF TEMP >100 F

INJ HAI SC/TID ACC TO GRBS

TAB PCM 650 MG RT /QID

TAB ECOSPRIN AV 7/10 RT HS

TAB STROCIT PLUS RT BD

NEB MUCOMIST 4TH HRLY

NEB IPRAVENT 4TH HRLY ,BUDECORT 8TH HRLY

RT FEEDS 100 ML MILD 4TH HRLY ,50 ML MILK 2 ND HRLY

Follow up on 15/1/25

FBS 140 PLBS 180 HBA1C 6.2

second followup on 19/2/25

HOME DEATH

Based on the provided case study, here's an analysis of the key concepts and ideas:

*Initial Codes and Labels:*

1. *Clinical Presentation:* Altered sensorium, hypoglycemic seizures, aspiration pneumonia, hypoxic encephalopathy, non-convulsive status epilepticus.

2. *Medical History:* Type II diabetes mellitus, hypertension, acute cholecystitis, diabetic ketoacidosis.

3. *Medications:* MixTard, Istamet, Levipil, Sodium Valproate, Piptaz, Clindamycin, Optineuron, Neomol, Hai, PCM, Ecosprin AV, Strocit Plus.

4. *Investigations:* Hemogram, FBS, PLBS, HbA1C, LFT, RFT, ABG, MRI Brain, 2D Echo, USG Abdomen and Pelvis.

5. *Treatment Outcomes:* Patient's condition deteriorated, and eventually, the patient died at home.

*Categorization:*

1. *Patient Profile:*

- Medical History

- Medications

- Family History

- Personal History

2. *Clinical Findings:*

- Altered sensorium

- Hypoglycemic seizures

- Aspiration pneumonia

- Hypoxic encephalopathy

- Non-convulsive status epilepticus

3. *Investigations:*

- Laboratory tests (Hemogram, FBS, PLBS, HbA1C, LFT, RFT, ABG)

- Imaging studies (MRI Brain, 2D Echo, USG Abdomen and Pelvis)

4. *Treatment and Outcomes:*

- Medications

- Treatment outcomes (patient's condition deteriorated, and eventual death)

*Theme Identification:*

1. *Complexity of Diabetes Management:* The patient had a history of type II diabetes mellitus, hypertension, and acute cholecystitis, highlighting the complexity of managing multiple comorbidities.

2. *Importance of Glycemic Control:* The patient's HbA1C levels were elevated, indicating poor glycemic control, which may have contributed to the development of complications.

3. *Need for Comprehensive Care:* The patient's condition required comprehensive care, including management of diabetes, hypertension, and aspiration pneumonia.

4. *Challenges in Managing Critically Ill Patients:* The patient's condition deteriorated despite treatment, highlighting the challenges in managing critically ill patients with multiple comorbidities.

*Theme Representation:*

*Learning Points:*

1. *Early recognition and management of hypoglycemia* are crucial in preventing complications.

2. *Comprehensive care* is essential in managing patients with multiple comorbidities.

3. *Glycemic control* is vital in preventing complications in diabetic patients.

4. *Close monitoring* of patients with multiple comorbidities is necessary to prevent deterioration.

*New Insights:*

1. The case highlights the importance of considering the interplay between multiple comorbidities in patient management.

2. The patient's condition may have been influenced by factors such as medication adherence, lifestyle modifications, and underlying disease severity.

3. Further research is needed to understand the relationship between glycemic control and outcomes in patients with multiple comorbidities.

*Key Findings:*

1. The patient had a complex medical history with multiple comorbidities.

2. The patient's condition deteriorated despite treatment, highlighting the challenges in managing critically ill patients.

3. The importance of glycemic control and comprehensive care in managing patients with multiple comorbidities.