One thing that occasionally interests physicians is seeing the extremes of human physiology. The body can generate and withstand really remarkable perturbations, and from time to time, I am simply amazed by the patients I'm caring for. The last time I was in the ICU, I saw a diabetic patient with a glucose of 1700, 17 times normal. He had hyperosmolar hyperglycemic nonketotic coma, which we like to abbreviate "HHNK" (with various spellings). He had been unconscious for days, likely from an infection, and meanwhile, without his insulin, his glucoses became completely out of control. He came in extremely cold, profoundly dehydrated, and unresponsive. Yet after a day and a half in the intensive care unit, by the time we got his glucoses down to 200, he returned to his usual normal self. He left the unit the next day and returned home several days later.
This is by no means an unusual or even difficult intensive care unit case. But when I think of it, I pause because there is something simply ineffable about the resiliency of the human body. Most of the medicine that we practice is aimed at getting the human body back to its baseline homeostatic state.
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In ancient Greece, the asclepion was a healing temple dedicated to Asclepius, the God of Medicine. Asclepius learned the art of surgery from the centaur Chiron and had the ability to raise the dead. The Rod of Asclepius is a roughhewn branch entwined with a single serpent.
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Hi! I am Craig Chen, a third year resident physician in anesthesiology at Stanford Hospitals and Clinics. I went to medical school at the University of California, San Francisco. Prior to medical school, I studied philosophy and biology at Stanford University, along with a minor in creative writing.
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2 comments:
Hi Dr. Chen,
The other day, I saw a middle-aged type II diabetic lady who presented to outpt clinic with progressive expressive aphasia x 2 days. Family was concerned as this was not her usual self, and brought her in. Her language comprehension appeared to be intact, and she able to respond appropriately to questions, albeit with a limited vocabulary. She was not able to find the words that she wanted to say. Otherwise no recent illness, f/c, focal neuro deficits. No weakness or hypoesthesia. Her physical exam was unremarkable.
Her POC glucose came back around 550.
The provider was concerned about a CVA, as it seemed consistent with an event affecting Broca's area.
She was transported to the ED by ambulance. Haven't heard back whether CT/MRI of the brain revealed any findings.
What do you think? Still most likely a CVA? Or a unique presentation of HHS with the hyperglycemia and the gradual onset/ progressive nature of her symptoms? Just thought it was an interesting case and wanted to share!
What an interesting case! I think both diagnoses are on the differential and it would be prudent to rule them both out. It's not my area of expertise, but Broca's aphasia will often be associated with a right hemiparesis and oral apraxia because of nearby motor structures. Certainly HHS can present with this nonfluency and lack of other focal findings. Other possibilities on the DDX may include metabolic causes, delirium, substances, neurodegenerative disease, mass lesion, even seizures, etc.
Thanks for sharing! I hope you follow up and see what ended up being the diagnosis.
Of course, I have to put that nothing in this blog or comments should be construed as medical advice. The full disclaimer is at the bottom of asclepion.blogspot.com
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