11-11-2024
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 patients clinical problems with collective current best evidence based inputs.
ICU 1 75F with diabetes 20 yrs with history of recurrent hypoglycemia, was admitted last month too. Was brought here on 13/11/2024 with coma since morning. Currently still comatose. Yesterday dolls eye was absent as also noted by @PPM3 and today it's present sluggishly.
Sent her to ECG with@ PPM4 and @PPM5 to rule out suspectednon convulsive status as that was the reason being given for referral from a rural medical college to an urban medical college.
Lacunar infarcts in basal ganglia.
The usual MRI diagnosis of cranial microvasculopathy. wonder how they keep throwing this diagnosis with Fazekas grading when even histopathology is not able to tell us much when it comes to microvasculopathy @PPM2?
PPM 6 - Cause for her non convulsive status sir??
PPM 2 - What's the working diagnosis for recurrent hypoglycemia sir?
PPM 1 - Let's first prove that it's non convulsive status as diagnosed by the treating team.
PPM 1 -
The usual. Negligence and system failure!
One of the residents who took the history (but didn't write it) said she was apparently having hypoglycemia every night since last last few months as reported by the relatives who were not adviced any further as to what needs to be done. PaJR could have helped these scenarios big time but it's difficult to implement currently as our team is microsized. She was admitted here a month back and I await the EMR summary from Saidulu as the IP number was shared with him by @PPM7.
PPM 6 -
They got admitted 3 weeks ago I/v/o Pain abdomen with DKA sir..
Insulin dose was fixed and asked to come for followup,after 1 week but they didn't as they are busy in celebrating festival sir..
And since 2-3 days prior to admission she used to getup in the midnight at 1 am as she used to feel uneasy (attenders told that gabara aitundi ani lechedi) and then she used to drink some milk with ragi Java and sleep,and the same happened the day before admission,she drank Java at 2am and slept and found unresponsive in the morning for which they have taken to govt hospital and her GRBS then was 232 and while she came to our hospital,her sensorium was E2V2M4 with GRBS being 262 and there is no hypoglycemic episode since then..
Attenders denied any involuntary moments of limbs and history related to seizure..
And there is no documented evidence of hypoglycemia anywhere but we thought it as hypoglycemia and increase in sugars due to stress response and at admission her left upper limb was very rigid with Flexion at shoulder,elbow and wrist joint with normal reflexes of both upperlinbs and bilateral lower limbs reflexes were Absent,and right plantar extensor and left plantor mute...
Room air saturation maintained at admission with grunting present all over chest regions ,and slowly by night there is a fall in Saturation and was connected to Oxygen..
No improvement in her sensorium since then ..
Since admission there is persistent tachycardia with normal BP ...
K/c/o Diabetes mellitus..
Tobacco chewer..
Non alcoholic..
And at admission while giving deep pressure she has eye opening (conjugate eye moments to right upper corner) sir..
Pupils bilateral equal and reactivity to light present..
PPM 1 - Thanks . Well related history 👏👏
And today now ? Can check her out in the EEG room. Also share her EEG here asap.
PPM 2 - So no documented evidence of Hypoglycemia then?
PPM 6 - No sir.
PPM 1 -
Last discharge EMR summary 👇
Age/Gender : 70 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 16/10/2024 08:04 PM
Diagnosis
DIABETIC KETOACIDOSIS[RELIVED] TYPE II DIABETES MELLITUS HYPERTENSION
ACUTE CALCULUS CHOLECYSTITIS[RELIVED]
Case History and Clinical Findings
PATIENT CAME WITH COMPLAINTS OF PAIN ABDOMEN SINCE 2 DAYS HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 2 DAYS AGO THEN DEVELOPED PAIN IN EPIGASTRIC REGION INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE NO AGGRAVATING AND RELIEVING FACTORS
H/O VOMITINGS 2 EPISODES NO H/O FEVER
NO H/O BURNING MICTURITION NO H/O CONSTIPATION
PAST HISTORY:
K/C/O HTN SINCE 20YEARS
K/C/O DM 20 YEARS USING INSULIN NO SIMILAR COMPLAINTS IN PAST
H/O RENAL CALCULI OPERATED 20 YRS AGO
H/O HYSTERECTOMY 20 YRS AGON/K/O,EPILEPSY,TB,CVA,CAD.PERSONAL HISTORYAPPETITE NORMALSLEEP ADEQUATEBOWEL AND BLADDER MOVEMENTS REGULARNO ADDICTIONSFAMILY HISTORY NOT SIGNIFICANTGENERAL EXAMINATIONPATIENT IS CONSCIOUS COHERENT COOPERATIVENO PALLOR ICTERUS CYANOSIS CLUBBINGLYMADENOPATHY PEDAL EDEMAVITALSTEMPERATURE 98FBP 110/80MMHGPR 103BPMRR 22CPMSPO2 94%AT RAGRBS-201MG/DLSYSTEMIC EXAMINATIONCVS S1S2 HEARD NO MURMURSPA SOFT NT
CNS NO FOCAL NEUROLOGICAL DEFICIT RA BAE+ NVBS
OPHTHAL OPINION
IMPRESSION : NORMAL FUNDUS STUDY COURSE AT HOSPITAL:
70 YEAR OLD FEMALE PRESENTED WITH C/O PAIN ABDOMEN PATIENT WAS TREATED ACCORDINGLY BY DEPARTMENT OF GENERAL SURGERY IN VIEW OF PAIN ABDOMEN.LATER ON FURTHER EVALUATION FOUND TO HAVE DIABETIC KETOACIDOSIS FOR WHICH PATIENT WAS TRANSFERRED TO GENERAL MEDICINE.TREATMENT WAS GIVEN WITH ADEQUATE FLUIDS , INSULIN INFUSION.PATIENT IMPROVED.LATER SHIFTED TO S/C INSULIN AND PATIENT IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION
Investigation
COMPLETE BLOOD PICTURE (CBP) 16-10-2024 08:49:PMHAEMOGLOBIN 8.9 gm/dl 15.0-12.0
gm/dlTOTAL COUNT 10500 cells/cumm 10000-4000 cells/cummNEUTROPHILS 85 % 80-40
%LYMPHOCYTES 08 % 40-20 %EOSINOPHILS 02 % 6-1 %MONOCYTES 05 % 10-2
%BASOPHILS 00 % 2-0 %PLATELET COUNT 1.63SMEAR Normocytic normochromic anemia with neutrophelia
SERUM AMYLASE 16-10-2024 08:49:PM 26 IU/L 140-25 IU/LHBsAg-RAPID 16-10-2024 10:20:PM
Negative
Anti HCV Antibodies - RAPID 16-10-2024 10:20:PM Non ReactiveRFT 16-10-2024 10:20:PMUREA
35 mg/dl 50-17 mg/dlCREATININE 0.9 mg/dl 1.2-0.6 mg/dlURIC ACID 2.0 mmol/L 6-2.6
mmol/LCALCIUM 9.4 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.0 mg/dl 4.5-2.5 mg/dlSODIUM 136
mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 104 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 16-10-2024 10:20:PMTotal Bilurubin 3.05 mg/dl 1-0 mg/dlDirect Bilurubin 2.38 mg/dl 0.2-0.0 mg/dlSGOT(AST) 178 IU/L 31-0 IU/LSGPT(ALT) 181 IU/L 34-0
IU/LALKALINE PHOSPHATASE 319 IU/L 141-53 IU/LTOTAL PROTEINS 5.6 gm/dl 8.3-6.4 gm/dlALBUMIN 3.1 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.20POST LUNCH BLOOD SUGAR 18-10-2024
03:57:PM 149 mg/dl 140-0 mg/dl
ABG 19-10-2024 06:24:PMPH 7.35PCO2 14.8PO2 102HCO3 8.0St.HCO3 11.7BEB -16.5BEecf - 16.9TCO2 17.4O2 Sat 97.3O2 Count 10.2COMPLETE URINE EXAMINATION (CUE) 19-10-2024
06:28:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN
+SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil SERUM ELECTROLYTES (Na, K, C l) 19-10-2024 09:06:PMSODIUM 135 mmol/L 145-136
mmol/LPOTASSIUM 3.6 mmol/L 5.1-3.5 mmol/LCHLORIDE 102 mmol/L 98-107 mmol/LSERUM
ELECTROLYTES (Na, K, C l) 19-10-2024 10:27:PMSODIUM 135 mmol/L 145-136
mmol/LPOTASSIUM 3.2 mmol/L 5.1-3.5 mmol/LCHLORIDE 99 mmol/L 98-107 mmol/L
ABG 19-10-2024 10:27:PMPH 7.37PCO2 24.6PO2 98.7HCO3 14.0St.HCO3 16.6BEB -9.7BEecf - 10.2TCO2 29.7O2 Sat 97.6O2 Count 12.3
USG FINDINGS:
E/O MILD PERICHOLECYSTIC FLUID
E/O SLUDGE AND FEW HYPERECHOIEC FOCI LARGEST MEASURING 6MM IN PARTIALLY DISTENDED GALLBLADDER
GALLBLADDER SLUDGE IN CHOLECYSTITIS
E/O FEW CALCULI LARGEST MEASURING 3-4MM IN UPPER POLE IN RIGHT KIDNEY IMPRESSION :
GRADE 1 FATTY LIVER
ACUTE CALCULUS CHOLECYSTITIS TINY RIGHT RENAL CALCULI
2D ECHO CONCLUSION:
TRIVIAL TR/AR MILD MR
NO RWMA NO AS/MS SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION
GRADE 1 DIASTOLIC DYSFUNCTION NO PE/LV CLOT ABG 19/10
PH: 7.35 PCO2:14.8 PO2 :102 HCO3:8.0 ABG 20/10 PH: 7.37
PCO2:24.6 PO2 :98.7 HCO3:14.0 ABG 21/10 PH: 7.39 PCO2:24.3 PO2 :106 HCO3:14.7
Treatment Given(Enter only Generic Name)
DAY1
INJ.HAI INFUSION @60ML/HR IVF 2. BOLUS GIVEN
IVF NS @100ML/HR
IVF 5D @50ML/HR STARTED WHEN GRBS <200MG/DL INJ. METROGYL 500MG IV TID
INJ.TAXIM 1GM IV BD
INJ.KCL 2 AMP IN 500MLNS @75ML/HR DAY2:
BRIDGING DONE TO S/C INSULIN INJ.HAI S/C TID
INJ.NPH S/C BD
INJ PAN 40MG IV OD INJ ZOFER 4MG IV/BD
INJ. METROGYL 500MG IV TID INJ.TAXIM 1GM IV BD
Advice at Discharge
INJ.HUMAN MIXRAED 50/50 16U[BBF]-X-12U BD TAB.ISTAMET -M 50/100 PO OD X-1-X
START DIABETIC DIET
TAB.PAN 40MG PO OD FOR 7 DAYS WATCH FOR HYPOGLYCEMIA SYMPTOMS
HOME GRBS MONITORING
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 Date: 23/10/24 Ward:FMW Unit:III
PPM 2 - Did she have significant weight loss in the recent past? How many years of insulin use sir?
PPM 1 - @PPM6 may know.
PPM 6 - No significant weight loss sir.
PPM 1 - Thanks!
Doesn't appear to be having any seizures although unable to zoom and see but still doesn't look like siezures.
Clinical imageology cranial MRI
Coma clinical electrophysiology
PPM 6 - She is diabetic since 20 yrs sir...
Using insulin since 15 yrs....
During her previous admission 3 weeks ago she was on Inj.Human Mixtard 25-----X-----20 sir and
Tab.Istamet-M
PPM 2 - This sounds a lot like LADA to be honest.
Any reported literature on brain involvement and LADA? @PPM6
Also please could youlet me know if she has any tertiary complications like foot/ heart and kidney disease due to Diabetes? Recurrent infections?
PPM 8 - Age is 70, if was diagnosed 20 yrs ago, then she would be type II DM
PPM 1 - 👍
PPM 2 - I understand but she has been on insulin for nearly the entire durationof her diabetes and also LADA is much more likely to precipitate a DKA than type 2
PPM 1 - 👍
PPM 8 - 👍
PPM 1 - Hope she's back in ICU 1 and not referred to an urban medical collee from our rural medical college?
PPM 1 - What precipitated her DKA in the previous admission?
15-11-2024
[15/11, 16:16] Pushed Comm 1AI23: Sir she has the habit of having food at midnight since long time sir
[15/11, 16:17] Pushed Comm 1AI23: Earlier there were hypoglycemic episodes
So used to eat food
Later it became a habit itseems sir
[15/11, 16:17] Pushed Comm 1AI23: When she was admitted in AMC for DKA she never had hypoglycemia
But she used to ask for food
As she was hungry
[15/11, 16:18] PPM 1 -: She timed her meals with her hypoglycemia and shifted her dinner time to midnight!
This itself deserves to be published!
[15/11, 16:18] Pushed Comm 1AI23: She used to have her dinner at 6 pm sir
[15/11, 16:18] PPM 1 -: Share her last admission IP number quick
[15/11, 16:18] PPM 1: So midnight second dinner?
[15/11, 16:18] Pushed Comm 1AI23: Yes sir
[15/11, 16:19] Pushed Comm 1AI23: Even without hypoglycemia she used to feel hungry and ask for food
[15/11, 16:20] PPM 1: At midnight? How do we know even without? They wouldn't have tested her sugars everytime?
[15/11, 16:21] Pushed Comm 1AI23: In last admission also
As Said by attenders
She used to feel hungry at midnight itseems sir
But there was never hypoglycemia in hospital sir
[15/11, 16:27] Pushed Comm 1AI23: As said by attenders
She used to take
Mixtard 5u mrng 5u night
But what we advised is for
16u bbf
12u bd
Clinical imageology of a cranial MRI
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