Transcript NMS case
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 previouslycommenced 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 eaxmination – 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 – – – – 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 • rigidity noted bilaterally • increased reflexes • ? Diagnosis - transferred to Mater Hospital Mater Hospital • Physical examination unchanged – – – – Heart rate - 94 BP 199/90 Serum sodium 124 CPK - 453 2200 reviewed by Consultant – – – – – – – – Marked rigidity Pill rolling tremor fluctuating temp noted diaphoresis not related to temperature >20% Fluxuation 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 • Ecoli 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