Материал: 100_Cases_in_Clinical_Medicine

CASE 74: CONFUSION

History

An 86-year-old man has been in a residential home for 3 years since his wife died. He was unable to look after himself at home because of some osteoarthritis in the hips limiting his mobility. Apart from his reduced mobility, which has restricted him to a few steps on a frame, and a rather irritable temper when he doesn’t get his own way, he has had no problems in residential care.

However, he has become much more difficult over the last 36 h. He has accused the staff of assaulting him and stealing his money. He has been trying to get out of his bed and his chair, and this has resulted in a number of falls. On some occasions his speech has been difficult to understand. He has become incontinent of urine over the last 24 h. Prior to this he had only been incontinent on one or two occasions in the last 6 months.

The duty doctor is called to see him and finds that he is rather sleepy. When roused he seems frightened and verbally aggressive. He thinks that there is a conspiracy in the ward and that the staff are having secret meetings and planning to harm him. He is disorientated in place and time although reluctant to try to answer these questions.

He is a non-smoker and drinks 1–2 units a month. On a routine blood test 8 years ago he was diagnosed with hypothyroidism and thyroxine 100 mg daily is the only medication he is taking. The staff say that he has taken this regularly up to the last 36 h and his records show that his thyroid function was normal when it was checked 6 months earlier.

The staff say that he is now too difficult to manage in the residential home. They feel that he has dementia and that the home is not an appropriate place for such patients.

Examination

There is nothing abnormal to find apart from blood pressure of 178/102 mmHg and limitation of hip movement with pain and a little discomfort in the right loin.

INVESTIGATIONS

Question

• What should be done?

189

ANSWER 74

This is not the picture of dementia. The acute onset with clouding of consciousness, hallucinations, delusions, restlessness and disorientation suggest an acute confusional state, delirium. There are many causes of this state in the elderly. It can be provoked by drugs, infections, metabolic or endocrine disorders, or other underlying conditions in the heart, lungs, brain or abdomen.

There is no record of any drugs except thyroxine, although this should be rechecked to rule out any analgesics or other agents that he might have had access to or that might not be regarded as important.

The thyroid abnormality is not likely to be relevant. The lack of replacement for 2 days will not have a significant effect and the normal results 6 months earlier make this an unlikely cause of his current problem. The sugar is normal. Other metabolic causes such as renal failure, anaemia, hyponatraemia and hypercalcaemia need to be excluded.

The falls raise the possibility of trauma, and a subdural haematoma could present in this way. However, it seems that the falls were a secondary phenomenon. The most likely cause is that he has a urinary tract infection. There is blood and protein in the urine, he has become incontinent and he has some tenderness in the loin which could fit with pyelonephritis. We are not told whether he had a fever, and the white cell count should be measured.

If this does seem the likely diagnosis it would be best to treat him where he is, if this is safe and possible. He is likely to be more confused by a move to a new environment in hospital. There is every likelihood that he will return to his previous state if the urinary tract infection is confirmed and treated appropriately, although this may take longer than the response in temperature and white cell count. Treatment should be started on the presumption of a urinary tract infection, while the diagnosis is confirmed by microscopy and culture of the urine. The most likely organism is Escherichia coli, and an antibiotic such as trimethoprim would be appropriate, although resistance is possible and advice of the local microbiologist may be helpful. From the confusion point of view he should be treated calmly, consistently and without confrontation. If medication is necessary, small doses of a neuroleptic such as haloperidol or olanzapine would be appropriate.

KEY POINTS

•Acute changes in mental state need to be explained even in the elderly with baseline mental problems.

•In delirium, consciousness is clouded, disorientation is usual and delusions may develop. The onset is acute. In dementia, there is an acquired global impairment of intellect, memory and personality, but consciousness is typically clear.

190

CASE 75: UNCONSCIOUS AT HOME

History

A 21-year-old man is brought in to hospital at 5 pm. He was found unconscious in his flat by his girlfriend. She had last seen him at 8 pm the evening before when they came home after Christmas shopping. When she came to see him the next afternoon she found him unconscious on the floor of the bathroom. He had been well previously, with no known medical history. There was a family history of diabetes mellitus in his father and one of his two brothers.

His girlfriend had said that he had shown no signs of unusual mood on the previous day. He had his end of term examinations in psychology coming up in 1 week and was anxious about these but his studies seemed to be going well and there had been no problems with previous examinations.

He is a non-smoker. He drinks around 10 units of alcohol most weeks with occasional binges. He has taken ecstasy tablets in the past but has never used intravenous drugs.

Examination

He looked pale. There were no marks of recent intravenous injections. His pulse was 92/min, blood pressure 114/74 mmHg, respiratory rate 22/min. There were no abnormalities to find in the cardiovascular or respiratory systems. In the nervous system there was no response to verbal commands. Appropriate withdrawal movements were made in response to pain. The reflexes were brisk and symmetrical, plantars were downgoing. The pupils were dilated but responsive to light. In the fundi, the optic discs appeared swollen.

Questions

•What are the most likely diagnoses?

•What other investigations should be done immediately?

191

ANSWER 75

This young man has been brought in unconscious having been well less than 24 h previously. The most likely diagnoses are related to drugs or a neurological event. The first part of the care should be to ensure that he is stable from a cardiac and respiratory point of view. His respiratory rate is a little high. Blood gases should be measured to monitor the oxygenation and ensure that the carbon dioxide level is not high, suggesting hypoventilation.

The family history of diabetes raises the possibility that his problem is related to this. However, the speed of onset makes hyperglycaemic coma unlikely. One would expect a slower development with a history of thirst and polyuria over the last day or so. However, the blood sugar should certainly be checked. Hypoglycaemia comes on faster but would not occur as a new event in diabetes mellitus. It might occur as a manifestation of a rare condition such as an insulinoma. Other metabolic causes of coma such as abnormal levels of sodium or calcium should be checked.

A neurological problem such as a subarachnoid haemorrhage is possible as a sudden unexpected event in a young person. Where the level of consciousness is so affected, some localizing signs or subhyaloid haemorrhage in the fundi might be expected. If no other cause is evident from the initial investigations, a computed tomography (CT) scan might be indicated.

The most likely cause is that the loss of consciousness is drug related. Despite the lack of any warning of intent beforehand, drug overdose is common and the question of availability of any medication should be explored further. This would be likely to be a sedative drug. If there is any suspicion of this then levels of other drugs which might need treatment should be measured, e.g. aspirin and paracetamol.

The other possibility in somebody brought in unconscious is that they are suffering from carbon monoxide poisoning. The fact that it is winter and he was found in the bathroom where a faulty gas-fired heater might be situated increases this possibility. Patients with carbon monoxide poisoning are usually pale rather than the traditional cherry-red colour associated with carboxyhaemoglobin. Papilloedema can occur in severe carbon monoxide poisoning and might account for the swollen appearance of the optic discs on funduscopy.

Measurement of carboxyhaemoglobin showed a level of 32 per cent. He was treated with high levels of inspired oxygen and made a slow but full recovery over the next 48 h. Mannitol for cerebral oedema and hyperbaric oxygen are considerations in the management. The problem was traced to a faulty gas water heater which had not been serviced for 4 years.

KEY POINTS

•Drug overdose is the commonest cause of unconsciousness in young people, but other diagnoses must always be considered.

•Carboxyhaemoglobin levels should be measured in patients found unconscious indoors or in vehicles and after known exposure to smoke.

•In carbon monoxide poisoning marked hypoxia may be present in the absence of cyanosis.

192

CASE 76: HEADACHE

History

A 24-year-old man presents to an emergency department complaining of a severe headache. The headache started 24 h previously and has rapidly become more intense. He describes the headache as generalized in his head. He has vomited twice and appears to be developing drowsiness and confusion. He finds bright lights uncomfortable. There is no significant previous medical history or history of allergy. He smokes 10 cigarettes per day and drinks 24 units of alcohol per week. He is not taking any medication currently. He is a graduate student doing an MA in psychology. He lives with his female partner and they have two children aged 3 and 4 years.

Examination

He looks flushed and unwell. His temperature is 39.2°C. He has stiffness on passive flexion of his neck. There is no rash. His sinuses are not tender and his eardrums appear normal. His pulse rate is 120/min and blood pressure 98/74 mmHg. Examination of heart, chest and abdomen are normal. His conscious level is decreased but he is rousable to command and there are no focal neurological signs. His fundi are normal.

INVESTIGATIONS

Gram stain: result awaited

Questions

•What is the diagnosis?

•What are the major differential diagnoses?

•How would you manage this patient?

193