PATIENT CAME WITH COMPLAINTS OF BEING UNRESPONSIVE

 Case History and Clinical Findings

CHIEF COMPLAINTS ; PATIENT CAME WITH COMPLAINTS OF BEING UNRESPONSIVE SINCE 2 HOURS [6.00 AM]

HOPI ; PATIENT WAS APPARENTLY ALRIGHT AT 6.00 AM WAS ABLE TO DO HER ROUTINE DAILY ACTIVITIES FOLLOWING WHICH SHE WAS FOUND UNRESPONSIVE AND NO C/O INVOLUNTARY MOVEMENTS ,INVOLUNTARY MICTURITION ,DEFECATION,UPROLLING OF EYES , TONGUE BITE

PATIENT WAS TAKEN TO AREA HOSPITAL .GRBS WAS 32MG/DL SPO2 80% ON KA CONSERVATIVE WAS GIVEN [BLOOD GLUCOSE LEVELS WERE CORRECTED ,O2 INHALATION SUPPLEMENTATION INJ DERIPHYLLINE WAS GIVEN AND WAS SENT TO OUR HOSPITAL FOR FURTHER MANAGEMENT

HISORY OF PAST ILLNESS ; NO H/O SIMILAR COMPLAINTS IN THE PAST NO C/O FEVER ,VOMITING,LOOSE STOOLS,PAIN ABDOMEN ,SOB ,CHESTPAIN , PALIPITATIONS

PATIENT ATTENDARS GAVE HISTORY THAT PATIENT CONSUMED 6-8 TABLETS OF GLIMPIRIDE

N/K/C/O HTN ,DM , CVA ,CAD ,TB, ASTHMA

GENERAL EXAMINATION;

GENERAL EXAMINATION

PATIENT IS CONSCIOUS

NO PALLOR ,ICTERUS, CYANOSIS ,CLUBBING ,LYMPHADENOPATHY ,OEDEMA OF FEET

VITALS

BP 140/80MMHG

PR 93 BPM

RR 26CPM

TEMPERATURE 101.4F

SPO2 90%

STSTEMIC EXAMINATION

RS ; BAE PRESENT , NVBS

CVS ;S1 ,S2 HEARED

CNS ; NFND

PA ; SOFT NON TENDER

PROVISIONAL DIAGNOSIS :-

IMMEDIATE CAUSE TYPE 1 RESPIRATORY FAILURE

ANTECEDANT CAUSE ALTERED SENSORIUM SECONDARY TO METABOLIC ENCEPHALOPATHY [RECURRENT HYPOGLYCEMIA / HYPOXIA ] IMPENDING DESCENDING TRANSTENTORIAL HERNIATION

Investigation

04/4/24

SEROLOGY HIV NONREACTIVE

HB1AG NON REACTIVE

HCV NOON REACTIVE

DGT O + VE

HEMOGRAM

HB 13.4

TLC 14000

PLT 2.12

MCV 83.9

MCH 28.4

CUE;

ARB ++

SUGAR NIL

PUS CELLS 3.4

EPITHEILIAL CELLS 2-4

RFT

CREATININE 1.2

UREA 33

NA 145

K4

CL 106

URIC ACID 5.4

LFT

TB 0.65

DB 0.19

ALT 13

AST 41

ALP 181

TP 6.8

A/G RATIO 1.33

05/04/24

HEMOGRAM HB 13.5

TLC 16500

PLT 2.12

MCV 84.8

MCH 28.2

RFT

CREATININE 1.2

UREA 53

Na 137

K 4.7

CL 102

URIC ACID 2.9

6/5/24

SEROLOGY

RBS 156

HbA1C 6.6

HEMOGRAM

HB 13.1

TLC 16300

PLT 1.79

MCV 83.8

MCH 27.9

MRI BRAIN PLAIN WAS DONE. SHOWED-T2/FLAIR HYPERINTENSITY WITH RESTRICTION OF DIFFUSION INVOLVING BILATERAL CEREBRAL HEMISPHERES AND BILATERAL BASAL GANGLION.F/S/O SEVERE FORM OF HYPOXIC /HYPOGLYCEMIC BRAIN INJURY.DILATED PERIOPTIC CSF SPACES S/O RAISED ICT.MILD DOWNWARD DESCENT OF BRAIN STEM AND CEREBRAL TONSILS S/O IMPENDING DESCENDING TRANSTENTORIAL HERNIATION.

MDCT SCAN BRAIN PLAIN

;DIFFUSE CEREBRAL EDEMA

Treatment Given:-

RYLES FEEDS 100ML WATER 2ND HOURLY ,200ML MILK 4TH HOURLY

O2 SUPPLEMENTATION +2CO2 TO MAINTAIN SPO2 >96%

INJ MANNITOL 100MG/IV/TID

INJ THIAMINE 100MG /IN 100ML

INJ PAN 40MG IN/OD /7AM

INJ NEOMOL 74ML IU/SOS IF TEMP.101F

INJ MONOCEF 7GM IV/BD

T.DOLO 650MG /RT/SOS IF TEMP >F

INJ CEVIDIL 1G IV/SOS

INJ DIAZEPAM 2CC+3CC NS [SOS]

INJ LEVIPIL 500MG/IV/BD

Death summary:-

67 YEAR OLD FEMALE CAME TO CASUALITY WITH UNRESPONSIVE STATE SINCE 2 HOURS AT 6:00AM ON 4TH MAY WITH GCS E1V1M2 AND VITALS WAS BP 140/80MMHG PR 93BPM RR 26CPM SPO2 90% @ RA ,GRBS 110MG/DL TEMP 101F AND ON EXAMINATION CVS S1 S2 + NO MURMURS RS BAE+NVBS P/A SOFT AND NON TENDER PUPILS -B/L PIN POINT ALONG WITH PLANTAR EXTENSORS WERE BILATERAL.ABG TAKEN AND SHOWED PH 7.40 PCO2 30.7 PO2 58.7 SO292.1 HCO3 18.7MMOL/L PATIENT WAS INITIALLY TREATED IN OUTSIDE HOSPITAL FOR HYPOGLYCEMIA -GRBS 32MGDL AND REFREERD TO OUR HOSPITAL . PATIENT ATTENDARS GAVE A HISTORY OF CONSUMPTION OF ORAL HYPOGLYCEMIC DRUGS. PATIENT HAD REPEATED HYPOGLYCEMIC ATTACKS AND WAS TREATED WITH INJ 25D INFUSION, FOLLOWING WHICH HER BLOOD SUGAR LEVELS WERE STABILISED AFTER 1DAY AND CT BRAIN SHOWED DIFFUSE CEREBRAL EDEMA AND STARETED HER WON HYPERTONIC SOLUTION [MANNITOL] AND O2 SUPPLEMENTATION,RYLES FEEDS AND SUPPORTIVE CARE WAS GIVEN .FEVER SPIKES WERE SEEN INTERMITTENTLY AND TOTAL COUNT WAS INCREASED TO 16000.BLOOD AND URINE CULTURE WERE SENT AND THEN IV ANTIBIOTICS WERE STARTED

ON DAY 2 ; PATIENT WAS SEEN WITH ANISOCORIA AND REFLEXES WERE DIMNISHED ; MRI BRAIN PLAIN WAS DONE. SHOWED-T2/FLAIR HYPERINTENSITY WITH RESTRICTION OF DIFFUSION INVOLVING BILATERAL CEREBRAL HEMISPHERES AND BILATERAL BASAL GANGLION.F/S/O SEVERE FORM OF HYPOXIC /HYPOGLYCEMIC BRAIN INJURY.DILATED PERIOPTIC CSF SPACES S/O RAISED ICT.MILD DOWNWARD DESCENT OF BRAIN STEM AND CEREBRAL TONSILS S/O IMPENDING DESCENDING TRANSTENTORIAL HERNIATION.

ON DAY3; HER OXYGEN REQUIREMENT INCREASED TO 10L AND SATURATIONS WERE DROPPED AT 6.00AM ABG SHOWED PH 7.48 PCO2 27.6 PO2 44.6 HCO3 23.2 INDICATINGTYPE I RESPIRATORY FAILURE ANDTHERE WAS FUTHER DROP IN SATURATIONS ABD CENTRAL PULSE AND BP WERE NOT RECORDABLE . CPR WAS STARTED ACCORDING TO LATEST ACLS GUIDELINES AND CONTINUED FOR 30MIN .MEANWHILE PATIENT WAS INTUBATED,INSPITE OF ALL THE ABOVE RESUCITATIVE EFFORTS ,THE PATIENT COULD NOT BE REVIVED AND DECLARED DEAD AT 7:04AM.

IMMEDIATE CAUSE TYPE 1 RESPIRATORY FAILURE

ANTECEDANT CAUSE ALTERED SENSORIUM SECONDARY TO METABOLIC ENCEPHALOPATHY [RECURRENT HYPOGLYCEMIA / HYPOXIA ] S/O IMPENDING DESCENDING TRANSTENTORIAL HERNIATION