73/M in altered sensorium

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I have been given this case to solve in an attempt to understand the topic of  " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 73 y/o male came to the casuality in unconscious state since 12 pm yesterday.

The patient was apparently asymptomatic 3 days back. Then he had fall from bed, sustained injury over chest region. Went to local doctor and got treated (his bp there was 160/90 mmHg) with

1. Inj Mannitol 100mg IV stat

2. Tab Taxim 

3. Inj Decadron

4. Inj Hydrocortisone

5. Inj Lasix

The patient was c/c/c till yesterday morning. Then he went to the same doctor for follow up. Patiemt has not been responding to commands since 9 am. He became completely unconscious since 12 noon.

Not a k/c/o DM, HTN, TB, asthma, epilepsy.

PERSONAL HISTORY

Diet - Mixed

Appatite - Reduced since 10 days

Sleep - Adequate

Bowel and bladder - Disturbed

Addictions - Regular alcoholic 

FAMILY HISTORY

None significant 

GENERAL EXAMINATION

Pt is unconscious

Moderately built and nourished

Afebrile

No icterus, cyanosis, lymphadenopathy, clubbing, lower limb pitting edema. Hyper pigmented patches seen on chest.

BP 120/70 mmHg

PR 72 bpm

RR 9 cpm

SpO2 97% in room air

GRBS 80mg/dl

CVS

S1 S2 heard

No thrills and murmurs

RS

Dyspnoea -

Wheeze -

Trachea central

Breath sounds vesicular

P/A

Soft, non-tender, bowel sounds +

CNS

Pt is unconscious

No signs of neck stiffness

Power cannot be elicited

Hypertonia in all 4 limbs

Pupils sluggishly reacting to light

GCS 3/15

Reflexes          R           L

1. Biceps         -           -

2. Triceps        -          -

3. Supinator    -           -

4. Knee             -           -

5. Ankle             -           -

6. Plantar       mute      mute

Investigations

ABG

pH 7.5 

pCO2 32.7

pO2 67.1

HCO3 29.8

Serology negative

Hb 10.6

TLC 8400

RBC 3.8mill

PLT 1.85lakh

N,L,M,E,B 80,10,6,3,1

Na 128

K 4

Cl 90

Ca 9.2

Urea 32

Cr 1.3

Provisional  Diagnosis

Altered sensorium under evaluation

SOAP NOTES DAY 1

ICU BED 1

S

Pt  E2V4M2

O

Pallor -

Icterus -

Cyanosis +

Clubbing -

Lymphadenopathy -

Pedal edema -

Afebrile

BP 80/50 mmHg

RR 10cpm

SpO2 98% at room air

PR central pulse +

GRBS 102mg/dl

I/O 4000/2980

Pupils sluggish, reactive to light

CVS S1 S2 +

RS B/L crepts +

P/A soft, non tender

Motor 

Tone reeuced in all 4 limbs

Reflexes          R           L

1. Biceps         +           +

2. Triceps         +         +

3. Supinator     -           -

4. Knee             +          +

5. Ankle            +          +

6. Plantar       mute      mute

ESR 40mm

PT 15 sec

INR 1.11

APTT 31 sec

Na 124meq

K 3.4meq

Cl 90meq

Thyroid Profile

T3 <0.1ng/dl

T4 0.2ng/dl

TSH 71.35

A

ALTERED SENSORIUM SECONDARY TO MYXEDEMA COMA WITH 1ST DEGREE HEART BLOCK

P

1. IVF NS, RL at 150ml/hr

2. O2 inhalation

3. Ryles tube feeds 100ml water (4th hrly), 200ml milk with protein powder (4th hrly)

4. 8nj OPTINEURON 1amp in 100ml NS slow iv od

5. Head end elevation

6. Inj NA 2 amp in 46ml NS iv at 24ml/hr (to maintain MAP 55-65 mmHg)

7. Inj DOBUTAMINE 1 amp in 45ml NS at 20ml/hr

8. Tab LEVOTHYROXINE 100mcg

9. Nebulisation with BUDECORT and DUOLIN 6th hrly

10. Syp POTCHLOR 15ml in a glass of water/RT tid

11. Monitor vitals 2bd hrly

12. I/O charting

Review 2d Echo

Emergency pericardiocentesis done in view of refractory hypotension secondary to pericardial tamponade in MYXEDEMA crisis Patient..

Pre procedure vitals

Bp : 70/40 mmHg with NORAD 18 ml / hour and dobutamine 14 ml/ ur

PR: 84 bpm

Sp02 : 100 on RA

After the procedure the vitals 

Bp: 130/80 mmHg 

PR: 88 bpm

Sp02: 100 on RA

SOAP NOTES DAY 2

ICU BED 1

http://mahithguduri63.blogspot.com/2021/09/myxedema-coma.html

Endocinologist opinion taken. Tab THYRONORM 100mcg tid and Inj HYDROCORTISONE 100mg tid prescribed

S

Pt conscious, coherent, oriented to person 

Lethargic

Constipated (did not pass stools since 1 week)

O

Pallor -

Icterus -

Cyanosis +

Clubbing -

Lymphadenopathy -

Pedal edema -

Afebrile

BP 100/70 mmHg

RR 10cpm

SpO2 1pp% at room air

PR 74 bpm

GRBS 70mg/dl

I/O 3500/1600

CVS S1 S2 +

RS B/L crepts +

P/A soft, non tender

CNS E4V4M5

Motor 

Tone reduced in all 4 limbs

Reflexes          R           L

1. Biceps         +           +

2. Triceps        +           +

3. Supinator     -           -

4. Knee             +          +

5. Ankle            +          +

6. Plantar     flexion    flexion

Power             

UL                      4/5       4/5

LL                      4/5       4/5

Pericardial centesis done yesterday. 300ml of fluid removed.

Inv

Na 130

K 3.7

Cl 87

Trop I negative

Dengue negative

MP strip negative

Hb 7.2

TLC 6000

RBC 2.3 million

PLT 1.2 lakh

N 93

L 03

Pericardial fluid

Sugar 134

Protein 5.3

Amylase 35

LDH 412

A

ALTERED SENSORIUM SECONDARY TO MYXEDEMA COMA WITH 1ST DEGREE HEART BLOCK WITH HYPONATREMIA WITH PERICARDIAL TAMPONADE

P

1. IVF 2 x NS, 1x RL at 75 ml/hr

2. O2 inhalation

3. Fluid restriction

4. Ryles tube feeds 100ml water (4th hrly), 200ml milk with protein powder (4th hrly)

5. Inj OPTINEURON 1amp in 100ml NS slow iv od

6. Head end elevation

7. Inj NA 2 amp in 46ml NS (to maintain MAP 55-65 mmHg)

8. Inj KCL 2 amp in 500ml over 5 hours

9. Tab LEVOTHYROXINE 100mcg (7 am, 1 pm, 7pm 1 hr before feeding) (D2)

10. Inj HYDROCORTISONE 100mg iv 6th hrly (D2)

11. Nebulisation with BUDECORT and DUOLIN 6th hrly

12. Monitor vitals 2bd hrly

13. I/O charting

14. Temperature charting

SOAP NOTES DAY 3

ICU BED 1

http://mahithguduri63.blogspot.com/2021/09/myxedema-coma.html

S

Pt conscious

O

Pallor -

Icterus -

Cyanosis -

Clubbing -

Lymphadenopathy -

Pedal edema -

Afebrile

BP 100/60 mmHg

RR 12cpm

SpO2 98% at room air

PR 72 bpm

GRBS 180mg/dl

I/O 3500/1600

CVS S1 S2 +

RS - Bilateral air entry present with  NVBS +

P/A soft, non tender, no organomegaly.

CNS E4V5M6

Motor 

Tone normal in all 4 limbs

Reflexes          R           L

1. Biceps         +           +

2. Triceps        +           +

3. Supinator    +           +

4. Knee             +          +

5. Ankle            +          +

6. Plantar     flexion    flexion

Power             

UL                      4/5       4/5

LL                      4/5       4/5

Inv

LFT

T bil 1.36

D bil 0.38

SGOT 65

SGOT 20

ALP 134

Protein 4.0

Alb 2.36

A/G 1.44

Pericardial fluid

Vol 1.5 ml

App clear (with small clots)

Color yellow

Total counts 10 cells

Diff count 10 cells are lymphocytes

RBC nil

A

ALTERED SENSORIUM SECONDARY TO MYXEDEMA COMA WITH 1ST DEGREE HEART BLOCK WITH HYPONATREMIA WITH PERICARDIAL TAMPONADE

P

1. Fluid restriction

2. Feeds 100ml water (4th hrly), 200ml milk with protein powder (4th hrly)

3. Inj OPTINEURON 1amp in 100ml NS slow iv od

4. Head end elevation

5. Inj NA 2 amp in 46ml NS (to maintain MAP 55-65 mmHg)

6. Inj KCL 2 amp in 500ml over 5 hours

7. Tab LEVOTHYROXINE 100mcg (7 am, 1 pm, 7pm 1 hr before feeding) (D3)

8. Inj HYDROCORTISONE 100mg iv 6th hrly (D3)

9. Nebulisation with BUDECORT and DUOLIN 6th hrly

10. Monitor vitals 2bd hrly

11. I/O charting

12. Temperature charting

SOAP NOTES DAY 4

ICU BED 1

http://mahithguduri63.blogspot.com/2021/09/myxedema-coma.html

S

Pt conscious

O

Pallor -

Icterus -

Cyanosis -

Clubbing -

Lymphadenopathy -

Pedal edema -

Afebrile (97.2F)

BP 120/70 mmHg

RR 14cpm

SpO2 100% at room air

PR 89 bpm

GRBS 102 mg/dl

I/O 1550/1600

CVS S1 S2 +

RS NVBS +

P/A soft, non tender

CNS E4V5M6

Motor 

Tone normal in all 4 limbs

Reflexes          R           L

1. Biceps         +           +

2. Triceps        +           +

3. Supinator    +           +

4. Knee             +          +

5. Ankle            +          +

6. Plantar     flexion    flexion

Power             

UL                      4/5       4/5

LL                      4/5       4/5

Inv

Na 125

K 3.2

Cl 92

A

ALTERED SENSORIUM SECONDARY TO MYXEDEMA COMA WITH 1ST DEGREE HEART BLOCK WITH HYPONATREMIA WITH PERICARDIAL TAMPONADE

P

1. Fluid restriction

2. Feeds 100ml water (4th hrly), 200ml milk with protein powder (4th hrly)

3. Head end elevation

4. Inj NA 2 amp in 46ml NS (to maintain MAP 55-65 mmHg)

5. Inj KCL 2 amp in 500ml over 5 hours

6. Tab LEVOTHYROXINE 100mcg (7 am, 1 pm, 7pm 1 hr before feeding) (D4)

7. Inj HYDROCORTISONE 100mg iv 6th hrly (D4)

8. Nebulisation with BUDECORT and DUOLIN 6th hrly

9. Monitor vitals 4th hrly

10. I/O charting

11. Temperature charting

SOAP NOTES DAY 5

AMC BED 1

http://mahithguduri63.blogspot.com/2021/09/myxedema-coma.html

S

Pt conscious

O

Pallor -

Icterus -

Cyanosis -

Clubbing -

Lymphadenopathy -

Pedal edema -

Afebrile 

BP 110/70 mmHg

RR 14cpm

SpO2 99% at room air

PR 92 bpm

CVS S1 S2 +

RS NVBS +, creptotations in R ISA

P/A soft, non tender

CNS E4V5M6

Motor 

Tone normal in all 4 limbs

Reflexes          R           L

1. Biceps         +           +

2. Triceps        +           +

3. Supinator    +           +

4. Knee            +           +

5. Ankle           +           +

6. Plantar     flexion    flexion

Power             

UL                      4/5       4/5

LL                      4/5       4/5

Inv

Na 127

K 3.2

Cl 82

A

ALTERED SENSORIUM SECONDARY TO MYXEDEMA COMA WITH 1ST DEGREE HEART BLOCK WITH HYPONATREMIA SECONDARY TO SIADH

P

1. Fluid restriction

2. Head end elevation

3. Tab LEVOTHYROXINE 100mcg (7 am 1 hr before feeding) (D5)

4. Inj HYDROCORTISONE 100mg iv 6th hrly (D5)

5. Syp POTCHLOR 10ml in 1 glass water TID

6. Monitor vitals 4th hrly

7. I/O charting

8. Temperature charting

SOAP NOTES DAY 6

AMC BED 1

http://mahithguduri63.blogspot.com/2021/09/myxedema-coma.html

S

Pt conscious

O

Pallor -

Icterus -

Cyanosis -

Clubbing -

Lymphadenopathy -

Pedal edema -

Afebrile 

BP 110/70 mmHg

RR 15cpm

SpO2 98% at room air

PR 89 bpm

I/O 1110/1400

CVS S1 S2 +

RS NVBS +, creptotations in R ISA

P/A soft, non tender

CNS E4V5M6

Motor 

Tone normal in all 4 limbs

Reflexes          R           L

1. Biceps         +           +

2. Triceps        +           +

3. Supinator    +           +

4. Knee            +           +

5. Ankle           +           +

6. Plantar     flexion    flexion

Power             

UL                      4/5       4/5

LL                      4/5       4/5

Inv

Na 131

K 3.3

Cl 90

LFT

TB 1.49

DB 0.28

AST 48

ALT 25

ALP 169

Protein 4.9

Alb 2.6

A/G 1.15

A

ALTERED SENSORIUM SECONDARY TO MYXEDEMA COMA WITH 1ST DEGREE HEART BLOCK WITH HYPONATREMIA SECONDARY TO SIADH

P

1. Fluid restriction

2. Head end elevation

3. Tab LEVOTHYROXINE 100mcg (7 am 1 hr before feeding) (D5)

4. Inj HYDROCORTISONE 100mg iv 6th hrly (D6)

5. 2 amp KCl in 500ml NS IV over 5 hrs

6. Syp CREMAFFIN 15 ml po hs at 9 pm

7. Monitor vitals 4th hrly

8. I/O charting

9. Temperature charting

SOAP NOTES DAY 7

AMC BED 1

http://mahithguduri63.blogspot.com/2021/09/myxedema-coma.html

S

Pt conscious

O

Pallor -

Icterus -

Cyanosis -

Clubbing -

Lymphadenopathy -

Pedal edema -

Afebrile 

BP 110/70 mmHg

RR 13cpm

SpO2 98% at room air

PR 85 bpm

I/O 800/750

CVS S1 S2 +

RS NVBS +

P/A soft, non tender

CNS E4V5M6

Motor 

Tone normal in all 4 limbs

Reflexes          R           L

1. Biceps         +           +

2. Triceps        +           +

3. Supinator    +           +

4. Knee            +           +

5. Ankle           +           +

6. Plantar     flexion    flexion

Power             

UL                      4/5       4/5

LL                      4/5       4/5

A

ALTERED SENSORIUM SECONDARY TO MYXEDEMA COMA WITH 1ST DEGREE HEART BLOCK WITH HYPONATREMIA SECONDARY TO SIADH

P

1. Fluid restriction

2. Head end elevation

3. Tab LEVOTHYROXINE 100mcg (7 am 1 hr before feeding) (D5)

4. Inj HYDROCORTISONE 100mg iv 6th hrly (D7)

5. Syp CREMAFFIN 15 ml po hs at 9 pm

6. Monitor vitals 4th hrly

7. I/O charting

8. Temperature charting

SOAP NOTES DAY 8

AMC BED 1

http://mahithguduri63.blogspot.com/2021/09/myxedema-coma.html

S

Pt conscious

O

Pallor -

Icterus -

Cyanosis -

Clubbing -

Lymphadenopathy -

Pedal edema -

Afebrile 

BP 110/70 mmHg

RR 15cpm

SpO2 98% at room air

PR 89 bpm

I/O 1000/750

CVS S1 S2 +

RS NVBS +

P/A soft, non tender

CNS E4V5M6

Motor 

Tone normal in all 4 limbs

Reflexes          R           L

1. Biceps         +           +

2. Triceps        +           +

3. Supinator    +           +

4. Knee            +           +

5. Ankle           +           +

6. Plantar     flexion    flexion

Power             

UL                      4/5       4/5

LL                      4/5       4/5

A

ALTERED SENSORIUM SECONDARY TO MYXEDEMA COMA WITH 1ST DEGREE HEART BLOCK WITH HYPONATREMIA SECONDARY TO SIADH

P

1. Fluid restriction

2. Head end elevation

3. Tab LEVOTHYROXINE 100mcg (7 am 1 hr before feeding) (D6)

4. Inj HYDROCORTISONE 100mg iv 6th hrly (D8)

5. Syp CREMAFFIN 15 ml po hs at 9 pm

6. Monitor vitals 4th hrly

7. I/O charting

8. Temperature charting

Patient was discharged in hemodynamically stable with MRS - 0 ( normal function )

Case Discussion

The main mechanism for the development of hyponatremia in patients with chronic hypothyroidism is the decreased capacity of free water excretion due to elevated antidiuretic hormone levels, which are mainly attributed to the hypothyroidism-induced decrease in cardiac output.

https://pubmed.ncbi.nlm.nih.gov/27484454/

25% of patients with primary aldosteronism can have normal Potassium .

Primary aldosteronism (15-20%) is commoner than pheochromocytoma (0.6%)

http://emedicine.medscape.com/article/241381-overview