Acute confusional state

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					Acute confusional state

Case history
A 75 year old man presented with a four
week history of an acute confusional state,
marked weight loss, and deteriorating             blood gases were pH 7.365 (7.35-7.45), PO2     There is surrounding oedema and mass
mobility. After admission he suffered a           23.15 (>10.6) kPa, PCO2 −7.16 (4.7-6.0) kPa,   effect. The lateral ventricles are distorted and
grand mal seizure. He was known to have           and bicarbonate 30 (24-30) mmol/l.             displaced medially.
longstanding essential hypertension con-                                                         (3) Bronchogenic carcinoma with cerebral
trolled with atenolol and chlorthalidone.                                                            metastasis.
He had smoked 15 cigarettes a day for             Questions                                      (4) Hypokalemic alkalosis and hypona-
almost 40 years. He had previously worked         (1) What are the possible causes of this           traemia could be explained on the basis
as an electrician and had occasionally been           patient’s acute confusional state?             of secretion of ectopic adrenocorti-
in contact with asbestos sheets.                  (2) Describe the chest x ray and computed          cotrophic hormone and antidiuretic
   On examination he was drowsy with a                tomography head findings                       hormone, respectively.
Glasgow coma scale of 8/15, haemodynami-          (3) What is the diagnosis?                     (5) Calculated serum osmolality using the
cally stable with a blood pressure of             (4) What is the likely explanation for the         formula [2(Na+K)+urea+glucose] is
108/60 mm Hg, and a heart rate of 76                  electrolytes and bicarbonate?                  301.3 (normal range 275-305) mmol/kg.
beats/min with an irregular rhythm. He was        (5) What is the calculated serum osmolality?
apyrexial and there were no obvious signs of                                                      Non-metastatic effects
sepsis. Chest examination revealed tracheal
                                                                                                  G Hypertrophic pulmonary
deviation to the left, decreased left sided       Answers:
chest expansion, normal breath sounds and         (1) (a) Cerebrovascular accident                   osteoarthropathy
no additional sounds. Neurological examina-           (b) Intracranial haemorrhage                G Thrombophlebitis migrans
tion revealed left sided signs with decrease in       (c) Hyperglycaemia                          G Non-bacterial thrombotic endocarditis
power of 4/5, normal reflexes, and up going           (d) Sepsis elevated white cell count in     G Anaemia, pruritus, herpes zoster
plantar.                                                  absence of clinical signs
                                                                                                  G Acanthosis nigricans and Erythema
                                                      (e) Malignancy
                                                      (f) Hypercapnia                                gyratum repens
Investigations on admission                           (g) Space occupying lesion                  G Gynaecomastia
Haemoglobin 14.0 (normal range 11.0-16.5)             (h) Depression                              G Endocrine—Syndrome of inappropriate
g/l, white cell count 9.79 (4-11) × 109/l,            (i) Constipation                               secretion of antidiuretic hormone
platelets 418 (140-400) × 109/l, erythrocyte          (j) Temporal lobe epilepsy                     secretion, ectopic adrenocorticotrophic
sedimentation rate 60 (0-10) mm in first              (k) Rapid dementia process
                                                                                                     hormone, and parathormone
hour, albumin 24 (35-50) g/l, phosphate           (2) The chest x ray film shows loss of the
1.09 (0.75-1.40) g/l, corrected calcium 2.38          aortic arch and right heart border, loss    G Neuropathy—Peripheral neuropathy,
(2.22-2.56) g/l, alkaline phosphatase 110             of cardiac silhouette sign, and an ele-        encephalopathy, cerebellar degenera-
(30-120) g/l, sodium 132 (135-145) g/l,               vated left hemidiaphragm. There is com-        tion
potassium 3.4 (3.7-5.0) g/l, urea 8.2 (3.5-8.0)       plete left upper lobe and lingular          G Proximal myopathy, polymyositis, and
g/l, creatinine 136 (50-105) g/l, glucose             collapse and hyperinflated right lung.         dermatomyositis
22.3 g/l, haemoglobin A1c 9.7% (3.6%-                The computed tomographic scan of the
                                                                                                  G Eaton-Lambert syndrome—reversed
6.8%), C reactive protein 59 (<10).               head shows multiple metastatic deposits in
   Liver and thyroid function test results        the right frontal lobe and right side of the
were normal. On 4 litres of oxygen, arterial      brain stem extending to the right thalamus.

454                                                                                 STUDENT BMJ VOLUME 10   DECEMBER 2002

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Description: Acute confusional state