A 65 year old female who was brought unconsicous to ED in the morning. Diabetes and Hypertension present too RBS -400 BP 180/100 Urine ketone Negative KFT,LFT,URINE RM- All WNL Have had one episode of seizure and one episode of vomiting NCCT report attached

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Small sulcal calcification 2 to 3 mm only ,nothing major. Cause of unconsciousness probably TIA posterior circulation in view of diabetic state and hypertension ,and age of the Pt. The other possibility seizure followed by nonconvulsive status . Deranged metabolism ,kindly check other parameters for metabolic encephalopathy which can produce seizure and post ictal unconsciousness.At what time he developed One episode of seizure and one episode of vomiting ? DO AN EEG

Respected dr pt was unconscious than how she can wokeup it is some confusing statement hence i mentioned Pt is diabetic and hypertensive And uncontrolled As bsl is 400 And bp is 180/100 Pt is unconscious and Nccy shows calcified granuloma that should be old lesion Episode of convulsion Granuloma can be a cause for convulsion or epilepsy hence needs to be evaluated Control bp and sugar Shift the pt on insulin Take an opinion of neurologist

Thanx dr Sabista Naaz
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As there is history of uncontrolled HTN and DM with new onset seizure and vomiting 1st possibility for this case is stroke.. 2nd hypertensive encephalopathy 3rd metabolic encephalopathy Evaluate for following Please post CT film instead of report...!!!

Sir attached CT film
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NCCT is non contributory towards diagnosis of cause of coma High blood sugar, without ketone in urine- may be hyperosmolar nonketotic hyperglycemia coma . Hypertensin+ Though NCCT does not show an infarct, stroke may be the cause of coma and seizure Suggest MRI BRAIN , ABG , ECG , identification of infection, Hydration, IV Insulin, correction of electrolytes disturbances, AED, NEURO opinion

The statement is quite confusing however ddx 1. Stroke 2. Htn encephalopathy CT doesn't show sign of stroke however it's better to get a MRI done with DWI AND ADC images so we can detect stroke.

DKD Cerebral edema serious complication of type 1 diabetes and, much less commonly, of type 2 diabetes. Insulin and Dietary supplement Advice CBNAAT

Diabetic keto acidosis For granuloma R/O CNS tuberculosis Ad CBNAAT

@Sepuri Krishna Mohan Sir, need your help again.Sir, this patient was discharged on mixtard insulin 20units in morning and 10units in dinner. If she reaches the euglycemic goals, which OHA would be the best to take this patient on? She is on leviretecetam, clobazam, telma h.

Dear Dr Ajeet Singh, Thanks for tagging me to answer your question regarding follow up of the Metabolic Parameters. I am always at your service 24/7. Don't hesitate to tag me dear Ajeet. If the patient reaches the glycemic targets, you can stop Insulin Biphasic Premixed and put her on OAD. STart with a combination of Tab Glimepiride 1 mg BD Plus Tab Metformin 1000 mg BD, in case she is either Over Weight OR Obese ie BMI of more than 23.5 kg/m2. Confine to Tab Metformin 500 mg BD along with Tab Glimepiride 1 mg BD if she is normal weight ie BMI less than 23.5 kg/m2. Based on the Blood sugar levels, you can titrate the dose of Glimepiride to 2 mg or 3 mg BD. You can even add Tab Vildagliptin 50 mg BD as now it is available at an affordable cost of Rs 5/-, each Tablet. Continue Levireticetam Clobazam Best is in stead of Telmisartan plus Hydrochlorothiazide, 40/12.5, you replace Chlortalidone 12.5 mg in place of Hydrochlorothiazide. Tab Chlorthalidone has good CV outcomes. Add Tab Methylcobalamine 1500 mcg when ever the patient is on Metformin as it interferes with Metabolism of Vitamin B12, which leads to Vit B12 Deficiency. As you had asked me to to focUs on the follow up of the case hence I stop here. Otherwise I would have much got into the main subject which is of more interest. Regards and thanks, Dr Sepuri Krishna Mohan.
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Is there any focal deficit ?? That granuloma reported may be incidental finding along with stroke...!!!

Diagnosis : DKA with uncontrolled HTN going in to Stroke For CT report rull out Kochs

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