A 26 year old lady presents from home confused with a low-grade fever. Her blood pressure is 160/100 mm Hg. She has no gross motor deficits. Ten days ago she had an emergency termination of pregnancy for an intrauterine death that was complicated by disseminated intravascular coagulation. She was 32 weeks gestation and had been on labetalol for a pregnancy-induced hypertension.
Her discharge medications included paracetamol, tramadol and a selective serotonin reuptake inhibitor. She has a 6-year history of uncomplicated Hepatitis C.
27.1. List the differential diagnoses for her confusion and temperature.
27.2. Outline your approach to establishing the diagnosis.
College Answer
27.1. List the differential diagnoses for her confusion and temperature.
Pregnancy related: Eclampsia / preeclampsia / HELLP, Retained products with sepsis, Sheehan’s syndrome / pituitary apoplexy, Posterior reversible encephalopathy syndrome (PRES), Hypertensive encephalopathy
Primary neurological: Infection (meningitis / encephalitis), cerebral venous thrombosis, seizure disorder, other cerebro-vascular
Metabolic: Sodium (hypo/hyper), Glucose (hypo/hyper), Renal failure, Liver failure (HCV / Paracetamol / Antidepressants),
Drugs: Accidental / intentional overdose, drug reactions (serotonin syndrome) Infection: Uterine, intracranial, other (renal, chest etc)
27.2. Outline your approach to establishing the diagnosis.
History: Collateral, Pregnancy issues, Ongoing blood loss, bleeding / bruising, drug ingestions, mood / affect, headaches
Examination: BP, uterine size / discharge, oedema, meningism, neurological (tone, reflexes, symmetry), chronic liver disease
Investigations:
FBC: Bleeding, platelets, WCC
UEC: urea / creatinine, Na, Ca, glucose
Coagulation: DIC, INR for CLD
LFT / Ammonia: hepatic encephalopathy, drug reactions
ABG: hypoxia / hypercarbia
Urinary drug screen / paracetamol level
Sepsis Screen, CT head +/- LP
Discussion
The college have presented a high quality systematic answer.
One can generate no better differentials for this decreased level of consciousness. They even included cerebral venous thrombosis.
The history is rich in possibilities.
Vascular causes:
- cerebral venous thrombosis
- PRES
- Hypertensive encephalopathy
Infectious causes
- Sepsis due to retained products
- Meningitis / encephalitis
Neurological causes
- Seizures (potentiated by tramadol)
- Serotonin syndrome
Drug related
- Intoxication
Autoimmune
- Cerebral vasculitis
Traumatic
- Head injury
Endocrine/metabolic/electrolyte related
- Hyponatremia
- Hypoglycaemia
- Hepatic encephalopathy (HELLP)
- Uremia
A genric approach to the unconscious patient in the ICU is available locally.