A 26-year-old female presents from home confused with a low-grade fever. Her blood pressure is 160/100 mmHg. She has no gross motor deficits on neurological examination.
Ten days prior to this presentation, she had induction of labour and delivery of a still-born foetus, at 32 weeks gestation, complicated by disseminated intravascular coagulation. She had been on labetalol for pregnancy-induced hypertension.
Her discharge medications included paracetamol, tramadol and a selective serotonin reuptake inhibitor. She has a six-year history of uncomplicated Hepatitis C infection.
a) List the differential diagnoses for her confusion and temperature.
b) Outline your approach to establishing the diagnosis.
a)
Pregnancy related: Eclampsia / preeclampsia / HELLP, 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)
b)
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 / hypercardia
Urinary drug screen / paracetamol level
Sepsis Screen, CT head +/- LP
This works better if it is presented in the form of a table
Causes | Investigations |
Vascular causes:
|
|
Infectious causes:
|
|
Drug-related causes:
|
|
Intrinsic neurological cause
|
|
Autoimmune causes
|
|
Traumatic or environmental causes
|
|
Endocrine and metabolic causes:
|
|
Differentials specific to pregnancy:
|
|
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