Episode 374 – Rafael Medina Subspecialty Episode – Acute encephalopathy and unresponsiveness
Jan 17, 2025
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Dr. Paul A. Bergl, an intensivist passionate about diagnostic reasoning, joins Dr. Meghan Nothem, a Pulmonary & Critical Care Medicine fellow. They analyze a perplexing case of a 50-year-old man found unresponsive. Topics include the nuances of diagnosing acute encephalopathy, with emphasis on patient history and systemic causes. They explore lab and imaging findings, the implications of metabolic disorders, and the challenges of toxic alcohol intoxication. Their discussion highlights the importance of critical thinking and collaboration in complex medical scenarios.
The podcast discusses the role of accurate patient histories in guiding differential diagnoses for acute encephalopathy cases.
Experts highlight the complexities of managing patients with end-stage renal disease, including atypical presentation of infections and medication complications.
A significant case conclusion reveals isopropanol intoxication from topical pain management, emphasizing risks associated with common treatments in vulnerable populations.
Deep dives
AI Medical Scribe Revolutionizes Documentation
Freed is introduced as an AI medical scribe designed to assist clinicians by automating the documentation process. It listens during patient consultations, transcribes conversations, and generates clinical notes in the clinician's personal style, significantly reducing the time spent on charting. By utilizing Freed, clinicians can save up to two hours daily, which enables them to focus more on patient care rather than paperwork. The platform's ease of use and HIPAA compliance make it suitable for various specialties in both in-person and virtual settings.
Complex Case Presentation in Pulmonary and Critical Care
A case involving a 50-year-old male with altered mental status is presented, detailing his clinical journey through the emergency department and subsequent evaluations. Healthcare professionals explore potential diagnoses, including neurological events, circulatory shock, and metabolic disorders. The case emphasizes the importance of gathering accurate and thorough patient histories to contextualize clinical symptoms and guide differential diagnoses. Discussions highlight the collaborative efforts of the medical team to derive the most accurate assessment based on presented evidence.
Key Clinical Considerations for End-Stage Renal Disease Patients
The patient's medical history reveals end-stage renal disease (ESRD), prompting discussions on common complications and appropriate clinical approaches. Experts remind listeners of the typical syndromes seen in dialysis patients, such as atypical presentations of infections that may lack classic symptoms. Understanding the nuances of how systems interact in ESRD leads to critical thinking about patient management protocols, including potential complications from medications typically used in these patients. This knowledge enhances clinicians' abilities to recognize and address the complexities presented by patients with chronic illnesses.
Investigation of Neurological Symptoms and Diagnosis
The medical team meticulously assesses the patient's neurological status and aims to identify the underlying cause of his symptoms. Initial imaging and laboratory tests including a CT scan and serum glucose levels are evaluated to rule out major brain injuries and metabolic disorders. As information accumulates, the risks are discussed regarding patients exhibiting potential encephalopathy symptoms and ensuring timely intervention to protect their airway and prevent further deterioration. The importance of ongoing monitoring and reassessment highlights the dynamic nature of critical care medicine.
Uncovering the Cause: Isopropanol Intoxication
Further investigation reveals significant elevations in isopropanol levels, leading to the hypothesis of isopropanol intoxication due to extensive topical application of rubbing alcohol for chronic pain management. The case illustrates how common treatments can unexpectedly result in severe toxicity, especially in vulnerable populations like those with ESRD. The rapid accumulation of knowledge through collaboration among team members results in a timely diagnosis and the initiation of appropriate treatments, including supportive care and dialysis. This case becomes a poignant teaching moment about the necessity of comprehensive patient histories and awareness of potential self-treatment harms.
In this Pulmonary & Critical Care episode, Dr. Meghan Nothem presents an unusual case of acute encephalopathy and unresponsiveness to Dr. Paul A. Bergl. Stay tuned to found out the final diagnosis!
Dr. Paul A. Bergl is an intensivist at Gundersen Lutheran Medical Center in La Crosse, WI and clinical adjunct assistant professor with the University of Wisconsin. He completed medical school at the University of Wisconsin-Madison, internal medicine residency at the University of Chicago, and critical care fellowship at the Medical College of Wisconsin.
Dr. Bergl is a decorated educator with over a dozen major teaching awards and honors from medical students, residents, and fellows. His foremost passions in medical eduation are critical thinking and diagnostic reasoning. His other scholarly work has focused on diagnostic error, point-of-care ultrasonography and echocardiography, and bedside teaching and rounding.
Case presenter: Dr. Meghan Nothem
Dr. Nothem is a third year Pulmonary & Critical Care Medicine fellow at The Medical College of Wisconsin in Milwaukee, Wisconsin where she also completed her Internal Medicine residency and served as Chief Resident. Prior to returning to her home city for post-graduate training, she earned her Bachelor of Science in Biology at University of Wisconsin-Madison and her medical degree at Rocky Vista University College of Osteopathic Medicine in Parker, Colorado. Dr. Nothem will be joining a Pulmonary and Critical Care Medicine practice in Milwaukee upon completion of her fellowship in summer of 2025.
