A NEJM Case 76 Male

 I fed this report from NEJM into GPT4 for a diagnosis.

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https://www.nejm.org/doi/story/10.1056/feature.2023.01.01.100096

I used a simple text cut/paste which loses formatting.  Labs were presented in a JPEG table, so I wasn't able to cut and paste them, putting the AI at a disadvantage.

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Presentation of Case

 

Dr. George Karandinos (Medicine): A 76-year-old man was evaluated in the emergency department of this hospital because of dizziness and altered mental status.

On the day of the current evaluation, the patient was observed crawling on a city sidewalk. He appeared pale and diaphoretic. On evaluation by emergency medical services, he reported feeling dizzy and “weird.” A fingerstick blood glucose level was 152 mg per deciliter (8.4 mmol per liter). He was brought to the emergency department of this hospital for further evaluation.

In the emergency department, the patient could not recall recent events, but he reported shortness of breath, as well as chronic back pain and persistent ringing in the ears. He was unable to give additional details of his history, but he provided the name of the hospital where he routinely received care. On a phone consultation, physicians at that hospital reported that the patient had a history of traumatic brain injury, post-traumatic stress disorder, seizure disorder, chronic back pain due to spinal stenosis, hypertension, diabetes mellitus, dyslipidemia, chronic kidney disease, gastroesophageal reflux disease, and anxiety. Prescribed medications included lisinopril and transdermal lidocaine. There were no known drug allergies. The patient had consumed alcohol in the past but not for 40 years. His family history was unknown.

The temporal temperature was 36.6°C, the heart rate 92 beats per minute, the blood pressure 183/113 mm Hg, the respiratory rate 27 breaths per minute, and the oxygen saturation 99% while the patient was breathing ambient air. The patient appeared disheveled and diaphoretic. He was somnolent but awakened to verbal stimuli. He was oriented to person, place, and time but only intermittently followed commands. A small superficial skin abrasion was noted above the left eyebrow. There was mild tenderness on palpation of the midback but no other evidence of trauma. The remainder of the examination was normal.

Table 1. Laboratory Data.

Table 1

Figure 1. Initial Imaging Studies.

Figure 1

An axial image from CT angiography of the head (Panel A), obtained before the administration of contrast material, shows nonspecific mild white‑matter changes (arrowheads) and a nonspecific small right‑peritrigonal calcification (arrow). A coronal image from CT angiography of the chest (Panel B), obtained after the administration of contrast material, shows no pulmonary edema, consolidation, or pneumothorax. An axial image from CT angiography of the abdomen (Panel C), obtained before the administration of contrast material, shows a left adrenal nodule (arrow) with an attenuation level of less than 10 Hounsfield units, a finding consistent with an adenoma.

Figure 2. MRI of the Head.

Figure 2

MRI of the head confirmed the findings on CT, showing no acute or subacute infarction, mass, or acute intracranial hemorrhage. A T2‑weighted fluid‑attenuated inversion recovery (FLAIR) image (Panel A) and a susceptibility‑weighted image (Panel B) show right‑peritrigonal signal abnormalities (arrows) that correlate with the small calcification observed on CT, a finding suggestive of either a calcified cavernous malformation or sequelae of previous infection or inflammation. The T2‑weighted FLAIR image (Panel A) also shows nonspecific mild white‑matter changes (arrowhead). A diffusion‑weighted image (Panel C) shows no abnormal restricted diffusivity.

Point-of-care ultrasonography, performed with an approach known as FAST (focused assessment with sonography for trauma), showed no abnormalities. The blood ethanol level was undetectable, and urine toxicologic testing was negative for amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, and opiates. The blood levels of lipase, magnesium, and N-terminal pro–B-type natriuretic peptide were normal, as were results of liver-function tests. There was mild normocytic anemia, but the complete blood count with differential count was otherwise normal. Other laboratory test results are shown in Table 1. Testing of a nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 was negative. Samples of blood and urine were obtained for culture. An electrocardiogram showed sinus rhythm, intraventricular conduction delay, left axis deviation, and nonspecific minor ST-segment and T-wave abnormalities. Imaging studies were obtained.

Dr. Brooks P. Applewhite: Radiographs of the chest and pelvis showed no acute abnormalities. Computed tomographic (CT) angiography of the head and neck (Figure 1A) revealed nonspecific mild white-matter changes, a nonspecific small focal calcification in the right-peritrigonal white matter, atherosclerosis without high-grade cerebrovascular stenosis, and multilevel spondylotic changes without severe spinal canal stenosis. There was no evidence of acute intracranial hemorrhage or territorial infarction. CT angiography of the chest, abdomen, and pelvis (Figure 1B and 1C) revealed no evidence of aortic dissection, pulmonary embolism, pneumothorax, pulmonary edema, lung consolidation, or pericardial effusion. There was a left adrenal nodule that measured 19 mm in diameter, a finding consistent with an adenoma.

Dr. Karandinos: Normal saline with 5% dextrose was administered intravenously. During the next 8 hours, the patient was agitated and combative. He repeatedly removed peripheral intravenous catheters and disconnected monitors. He was no longer oriented to place or time. Two doses of olanzapine were administered intravenously, and the patient slept for several hours during the night.

Sixteen hours after the patient arrived in the emergency department, the temporal temperature was 37.7°C, the heart rate 78 beats per minute, the blood pressure 160/72 mm Hg, the respiratory rate 20 breaths per minute, and the oxygen saturation 100% while he was breathing ambient air. The patient was observed to be breathing deeply. He was able to state his name, but his speech was otherwise nonsensical and dysarthric. He followed commands only when visual cues were given; for example, he stuck out his tongue after the examiner demonstrated the task. Motor, sensory, and reflex examinations were normal; tests of cerebellar function were not performed. Additional laboratory test results are shown in Table 1. The results of electroencephalography (EEG) were normal, without epileptiform abnormalities. Normal saline with potassium chloride was administered intravenously, as was lorazepam. Additional imaging studies were obtained.

Dr. Applewhite: Magnetic resonance imaging (MRI) of the head (Figure 2) revealed no evidence of acute intracranial hemorrhage or acute or subacute infarction. T2-weighted fluid-attenuated inversion recovery images showed a mild burden of white-matter signal hyperintensities, which are nonspecific but typical of chronic small-vessel disease. The previously detected calcification in the right-peritrigonal white matter correlated with an 8-mm focus of T1 and T2 signal abnormalities with associated susceptibility blooming, a finding suggestive of either a calcified cavernous malformation or sequelae of previous infection or inflammation.

Dr. Karandinos: The patient’s mental status did not improve. Twenty-four hours after he arrived in the emergency department, he was admitted to the hospital with a working diagnosis of seizure. The temporal temperature was 37.6°C, the heart rate 77 beats per minute, the blood pressure 151/70 mm Hg, the respiratory rate 22 breaths per minute, and the oxygen saturation 98% while he was breathing ambient air. Respiratory effort appeared increased. He was somnolent, and he followed simple commands but did not open his eyes in response to sternal rub. The blood levels of creatine kinase, fibrinogen, and ammonia were normal. Other laboratory test results are shown in Table 1.

Thiamine was administered intravenously.

[DIAGNOSIS FOLLOWS AND DISCUSSION]