14-04-2025
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.
50F with coma and left sided conjugate eye deviation and as described by @~PPM 3 hypoactive delirium but what is hypoactive delirium? She had recently increased her alcohol consumption from a quarter bottle to one bottle of OC per day!
[14-04-2025 15.58] PPM 3: The case shared shows a 50-year-old female presenting with coma and left-sided conjugate eye deviation. The note references hypoactive delirium, which is a form of delirium characterized by reduced motor activity, lethargy, drowsiness, and decreased responsiveness—often making it harder to recognize compared to hyperactive delirium, which presents with agitation and restlessness.
Possible clinical insights:
History of increased alcohol intake (from a quarter to a full bottle of OC per day) suggests the possibility of alcohol-related encephalopathy, hepatic encephalopathy, or alcohol withdrawal syndrome.
The progress note (by Dr. PPM1) mentions:
Metabolic encephalopathy (possibly due to hepatic or alcoholic causes)
Hyponatremia
Alcohol dependence
Liver dysfunction (Acute hepatitis, Acute-on-chronic liver disease)
Hypoactive delirium:
It is often underdiagnosed due to its subtle presentation. It can be caused by:
Metabolic disturbances (like hyponatremia, hepatic encephalopathy)
CNS infections
Alcohol-related conditions
In this patient, alcohol dependence, possible liver dysfunction, and metabolic imbalance (likely hyponatremia) could all be contributing to a hypoactive delirium or encephalopathy state, mimicking coma.
Would you like a more detailed explanation of the CNS findings in the note or the approach to altered sensorium in alcohol-dependent patients?
[14-04-2025 16:03] PPM 2: Wernickes!!
[14-04-2025 16:03] PPM 4: Yes sir 😅
[14-04-2025 16:04] PPM 2: Plenty of wasting in the lower limbs as well, I'm sure she has alcoholic polyneuroapthy too!
[14-04-2025 16:07] PPM 3: Yes! Wernicke's encephalopathy is a key differential here, especially given:
Chronic alcohol use
Acute neurological deterioratio
Ophthalmoplegia or conjugate eye deviation
Altered mental status (coma/hypoactive delirium)
Possibly ataxia (though hard to assess in coma)
Classic triad of Wernicke’s
1. Ophthalmoplegia / nystagmus / conjugate gaze palsies
2. Ataxia
3. Confusion / altered mental status
Even though the full triad is only seen in a minority of patients, suspecting Wernicke's early is crucial, because thiamine deficiency (B1) is the root cause, and it's treatable but often missed.
Management tip:
Always give IV thiamine before glucose in suspected Wernicke's to avoid precipitating or worsening the encephalopathy.
Given her alcohol dependence, liver dysfunction, and current presentation—Wernicke's is a strong contender. Would you want to explore Korsakoff’s psychosis or the transition from Wernicke’s next?
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