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Brain dysfunction due to low glucose and high BP - Online Doctor Chats

Date : 21-Feb-2012
User rating for this question
Very Good Posted in: Brain and Spine
Answered by

General & Family Physician
Practicing since : 2005
Answered : 2568 Questions
User :   A 62 (now 63) y.o. very intelligent female who has had multiple high-functioning and highly skilled professions, with hx. of TypeII diabetes, high BP controlled on meds, chronic pain treated w/ morphine; hx intermittent vomiting and diarrhea. Found disoriented June 3, 2009, said "cumcumber (her van) was in the driveway"; given glucose b4 ambulance called. Paramedics arrived and BS 33, BP 220/170, left-facial drooping, could see words she wanted to say but could not speak them. In hosp pt. writing messy, childlike, scribbled; stated Pres. was Nixon, yr. 1989 - later said she knew right answers and knew she was giving wrong answers--she could not say what she intended to speak. Brain MRI no stroke, no bleed. Drs wanted to blame S/S on taking "too much pain meds" but she has been on same dose for long time with no disorientation; drug screen showed NO unexpected levels. Post-hospital: Could not do these things--simple math; speak full sentences (word blockage); diff finding words; diff following simple or complex directions; confusion; forgetful; struggles to understand meaning of other people's words; lost many important items (keys, wallet, uncashed checks; credit/debit cards); wrote wrong years repeatedly June 09 to June '10---she'd write it was 1928, 1967, 1989, etc; often repeated written words in sentences; would get "lost" from room to room, forget what she was going to do. Greatly improved but has continued problems; on 3 of 7 days each week has very bad days. Her doc wonders if she has chronic adrenal insufficiency after repeated cortisone shots for back pain. Biggest S/S now, ALL intermittent include: (first 4 come and go quickly->)dizziness, bad nausea, loss of balance, confusion; (these recurr repeatedly-->)"sluggish"/tired; falls asleep during conversations; left-slide face droops; repeating written words even though she tries hard to write what she intends
User :   to write; tells me "I can only think of (whatever words she's stuck on, like "pretty people")" which she'll find she has written over and over (pretty people pretty people etc); verbal word substitution like "I put the cat (e.g. milk) in the refrigerator"; losing items; forgetfulness; gets "lost" in house; less spontaneously verbal since June 2009; less interest in previously high-interest subjects; stares hard at nothing when she can't speak words; recognizes people but forgets people's names she has known for years; word recall tests=zero but fair word recognition. Written perseverations interfere with her job. Her doc wants me to continue my observations since I am a retired RN. I wonder if intermittent TIAs but her Dr says no. I cannot find anything online about "written perseveration" when the patient knows what they intend to write but what gets written is something totally different; sometimes she recognizes the repetition, but often she does not. Examples of problem writing with crossed outs on repeats: 1.) Walked 5 minutes minutes 5 minutes walking minutes 5 wal walk walking" 2.) "old people did old people old people old peo people" 3.) Out of of of bread. Went went to to to store to store to store bread". She says she never intended to write these words at all; at the time she fully believes she is writing what she intends to write. She can verbally tell me the intended sentence without perseveration of any word but often has blocking--starts sentence--stops--struggles for next word--starts over-- blocks on a different word, etc. Now, BP and BS WNL except occ. very low BPs of 90/50. Can have all of the above S/S during higher BS of 172. On Glucaphage 1,000 BID; Glyburide 3mg BID; Enapril 30mg a day; Morphine ER 100mg BID; Simvastatin; Synthroid; anti-depressant at HS. Neuro said NOT dementia. Any ideas please?                              
Doctor :   Hi
Doctor :   let me read
User :   I tried to describe all of observable problems.
Doctor :   when she was taken to ER and MRI was taken what did the doctors say ?
User :   MRI done 48 hrs after admittance
Doctor :   ok
User :   Said no stroke, no bleed
User :   kept her in ER 24 hrs due to very low BS
Doctor :   ok
User :   ALL of what I described the docs in hospital saw/heard
User :   They also did swallow test-- ok
User :   I'm very worried; she lives alone & I think she needs new MRi
Doctor :   what was the provisional diagnosis the doc at ER made at the time of admission ?
User :   Took too much pain med; severe low BS; severe high BP
User :   They had her on 4 BP meds at discharge because BP would rise when on lower amounts
Doctor :   what was the BS at the time of admission
User :   Here with paramedics it was 33 AFTER I gave her glucose tabs
Doctor :   ok
User :   They gave glucose gel.. got it to 44 before transport
User :   We don't know time-line
User :   drove here 8pm... I found her disoriented at midnight
User :   I was asleep...
Doctor :   The low BS combined with the High BP has caused damage to her brain
User :   She was walking, talking, but "lost", disoriented, looked like drunk (does not drink)
Doctor :   yes
User :   Dr that is what I think too, but her Dr says NO
User :   She has had NO post therapy
User :   *I* am the only one helping her
Doctor :   ok
User :   I know if I had not found her she would have died, BS was likely in 20s before I found her
Doctor :   low glucose and high blood pressure temporarily causes brain dysfunction
Doctor :   and it will proceed to brain injury only left for some time in that state
User :   What is recovery time? Or will she continue to have BI symptoms for rest of life?
Doctor :   the incidence has impaired her intellectual and cognitive function
User :   I agree; why don't docs here agree?
Doctor :   once the brain is damaged than for the entire life it will be the same
Doctor :   what was the doc explanation for her present behaviour ?
User :   possible chronic adrenal insufficiency
User :   ran blood test on Monday; no results yet
User :   I am keeping a daily diary now of behavior/symptoms
Doctor :   ok
Doctor :   she is on antidepressant medications ?
User :   Yes but she cannot recall the name
Doctor :   did she had an psychiatric evaluation
User :   last was on Prozac but not now.... no psych eval
User :   Neuro eval done, no dementia
Doctor :   who prescribed the antidepressants ?
User :   This woman is 120% different NOW than pre-2009
User :   Family doc--internist--does all except pain meds
User :   When she acts weird it is "eerie" because we don't know whether we are seeing new TIA, low BS, or what
User :   She can "fool" people. if she does not talk 10 minutes at least, you might miss all of the signs
Doctor :   TIA is different
User :   Ok tell me, how would it be different?
User :   I need that info
Doctor :   i dont see any thing of that in her in any of your description
User :   ok -- relief
User :   She has slght less stregth in hand grip on left, but very slight
Doctor :   low BS can produce the symptoms
Doctor :   bit it will come in episodes and not constant
Doctor :   definitely she has a different behavior and this has appeared all after an hypoglycemic and hypertensive episode
User :   She acted funny Thurs night; said she was disoriented but she meant confused; we treated as if low BP but got meter within 10 minutes; BP was 172
User :   This is NOT constant
User :   In and out; ok all afternoon (or evening) then not ok
Doctor :   so it is there most of the time in a day
User :   ok all day for several days, then brain cuts in & out
User :   NO not there most of time each day
User :   It will come...and go... or stay for hours...then next day is ok
User :   Or, writing / wrong year goes on all week then OK
User :   she is JUST becoming aware of deficits too
Doctor :   low BS will be acute and it produces symptoms when the blood glucose goes down a critical level and SYMPTOMS GET ABORTED ONCE SHE IS SUPPLEMENTED WITH GLUCOSE
User :   It doesn't fit all the time
Doctor :   ok
User :   Like I would have sworn low BS thursday... I gave her chocolate milk and got meter... within 10 min of milk, BS was 172... so
User :   it could not have been low BS, right?
Doctor :   yes
User :   I had to get friend to drive her home thursday
User :   She could not speak words
Doctor :   ok
User :   She stopped mid sentence... staring
User :   "jane!" we'd say, then she'd be ok for couple minutes but confused
User :  
Doctor :   ok
Doctor :   since all her investigations have ruled out the possible brain damage and she continuous to have behavioral and cognitive function
User :   Which way would you go if she was your patient?
Doctor :   she needs an psychiatric evaluation
User :   nothing physical would explain it all?
User :   Is this how Alzheimer's looks in beginning?
Doctor :   your neuro has had a look and ruled out dementia
User :   yes that's what XXXXXXXX said, the neuro told her to NOT take med for dementia
User :   Would small dose of Exelon help her? I was put on Exelon for my forgetfulness & it helped me.
Doctor :   more so she has a behavioral problem
Doctor :   you need to get an psychiatric opinion for that
User :   Can you explain? I don't understand. How she is now is nothing like she was before the big incident in June 2009 with the low BS.
User :   Before... she could recall months ago.... phone numbers rarely called... all the long chemical names for meds... could add complex numbers in her head...
Doctor :   ok
User :   NOW, if i ask her to get 2 items at store, she has to write both down
Doctor :   yes it is the problem
User :   She has been an Air Tradfic Controller; an Episcopal priest; and a Nursing Aid
Doctor :   ok
User :   She can't speak a sermon now
Doctor :   ok
User :   She can't write it... skips words or repeats words
Doctor :   ok
User :   I have known her for 14 yrs. i don't think this is psych.
User :   She looks LOST
User :   Like a vulnerable child--when it is bad
Doctor :   ok
User :   I've had to have someone drive her home 4 x since June. In 30 days she had 4 accidents-- had a perfect driving record before June 2009
Doctor :   ok
User :   Could it be what her Dr thinks: chronic adrenal infufficiency??
Doctor :   may be
User :   Here's my big concern:: Do I need to make plans for her to live with me? is this treatable or will she decline more. That is my worry. She has no one but me.
Doctor :   yes she needs support
Doctor :   she is having some problem which is not yet diagnosed
User :   Sigh, Well, I'll keep doing my records and talk to her doctor again. This is certainly not a clear-cut situation.
Doctor :   first that needs to be done
User :   I appreciate your review of her case.
User :   And thank you for your ideas.
Doctor :   once a diagnosis is in hand further course of action can be addressed
User :   I hope!
Doctor :   thanks for consulting health care magic
User :   I'll let you go now; have a good evening (or day). :-)
Doctor :   bye for now
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