Transcript EVEN DELIRIUM

HYPOTHERMIA &
DELIRIUM
Andrew Dawson
15.11.02
• 50 year old man presents to JHH
• 1 week history or declining mobility and increased confusion
• ? associated with depot injection of flupenthixol - last dose one week
ago
• 3 days previously commenced on Cogentin 2mg bd by LMO
• Epilim 1gm bd.
• PH: variety of psychiatric Dx and previous head injury
• On Examination
– Smelly Confused, unable to give clear account of himself
– Clinically dehydrated
– Pulse 80, BP 160/90, Temp - 34.7, respiratory rate 20, arterial blood gases
- normal, blood sugar level - normal.
– Generally hypertonic increased rigidity ? Resisting examination
– brisk reflexes - no clonus,.
Investigations
• Haemoglobin 16, white cell count 6.7, platelets 267,prothrombin time normal, Iron - 20, CK - 87, serum sodium 143, K 4.2, urea 3.6,
creatinine -90.
• Chest X-ray normal
• Septic workup
– normal blood cultures,
– urine was found to be offensive,
• white cells were > 100, red blood cells < 10, squamous < 10, profuse rods.
• Commenced on Antibiotics Transferred to MMH
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8 hours later was much improved
with some mild rigidity in the right arm
no autonomic features, less flushed, no renal tenderness
No previous history of Urinary sepsis or renal disease
• Continued on ampicillin and Gentamicin
• the following day be was ambulant, feeding himself
• Discharged well 18.11.02
23.11.02
• Represents to JHH - wife states he has had decreased mobility over
the last 3-4 days despite being recommenced on Cogentin. ????
Further antipsychotics since his last admission. Wife claims that he
has difficulty swallowing and of pain in the throat.
• On examination - conscious, orientated to time and place, GCS - 15,
BP - 175/100, Pulse 95, Temp - 37, saturations 98%, respiratory rate 22.
• Generally hyper-reflexic
• cardiovascular and respiratory examination was normal uvula was
noted to be erythematous and red with small white plaques, tongue was
dry, white and furry.
Provisional diagnosis
• dehydration
• upper respiratory tract infection, throat tonsillitis
• drug reaction
Investigations
• Sodium -129
Potassium - 46
Chloride - 94
Bi-carb - 23
Urea - 4.8
Creatine - 89
Liver functions tests - normal
CPK - 2083
• Reviewed by ENT Registrar - noted ? Uvular, no pharyngitis or
tonsillitis, oral cavity pathology does not seem likely serology for
symptoms for this medical review.
• Three hours later seen by medical registrar - noted to be drowsy,
dehydrated and sweating.
• Temp - 36.6, BP 170/110
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rigidity noted bilaterally
• increased reflexes
• ? Diagnosis - transferred to Mater Hospital
Mater Hospital
• Physical examination unchanged
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Heart rate - 94
BP 199/90
Serum sodium 124
CPK - 453
2200 reviewed by Consultant
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Marked rigidity
Pill rolling tremor
fluctuating temp noted
diaphoresis not related to temperature
>20% Fluctuation in BP
No evidence of sepsis
24/11 commence on Bromocriptine 5mg 4th hourly
Urine analysis and electrolytes performed
25/11/02
• Clinical am
– BP flux resolved
– Stiff, sweating and delirium
– Osmolarity
• Plasma 261 mmol/kg
• Urine 927 mmol/kg
• Family interview
– wife 4 brothers 2 sisters and a couple of mates
• Medical diagnosis
• Psychiatric diagnosis
• Risk of further medications
• E.coli in urine
Progress
• 26/11/02
• Clinical
– Minimal rigidity, moving freely, feeding self and smoking
– Afebrile, no autonomic instability
– Delirium
• Reduce bromocriptine dose
• 27/11/02
– RMO asked to see patient because of increased urine output
– 630 ml in 3 hours (between midnight and 3 am)
• Subsequently weaned from bromocriptine over the next 4 weeks