A history of blackouts
Presentation 69 yo man with a history of blackouts BIBA to ED following loss of consciousness and partial seizure. Now stable, still unconscious.
HPC At home with wife. She found him dazed, leaning forward, incontintent of urine. Wife called GP. The GP came to the home. The patient then had transient, uncontrolled, coarse movements of his right arm and leg. What disease process might be suggested by above history?
Possible disease processes Very broad, given the vague history Need more info on the “history of blackouts” Need better description of “dazed” Partial seizure/s with LOC Metabolic: glucose, electrolytes, oxygen Neurological: epilepsy Neoplastic: brain tumour Vascular: infarction (MI, stroke, structural blockage), or haemorrhage (CVA?, haematoma, sinus thrombosis) Infective: meningitis, encephalitis, sepsis Trauma: head injury (concussion, contusion, hematoma) Drugs: alcohol withdrawal, amphetamines, cocaine Psychogenic pseudoseizures
Another seizure While being assessed in the Emergency department the man has further convulsions, but this time they are more generalised. He is able to maintain his own airway. What immediate action would the attending doctor take?
Seizure management The presentation is consistent with status epilepticus SE management (from Therapeutic guidelines):Therapeutic guidelines Manage airway and oxygenation Administer slow IV benzodiazepine: 1mg clonazepam, or 10-20mg diazepam (also as a rectal gel) orrectal gel 5-10mg midazolam (may be IV, IM, intranasal, or buccal)intranasal, or buccal Follow with longer acting anticonvulsant by slow IV: Phenytoin 15-20mg/kg, or Phenobarbitone 10-20mg/kg, or Sodium valproate 10mg/kg (max 800mg) Admit to ICU for general anaesthesia if seizures continue
Lab Investigations After initial management the patient’s condition stabilises, and IV access is gained. The house officer sends blood to the laboratory. Which blood tests would be requested and which specific abnormalities should be excluded?
DDx investigations Goal is to determine any underlying pathology FBC for possible infection U&E for serum Na, Ca, Mg, K, and urea Blood glucose Liver function tests Blood alcohol level Serum toxicology screen? Arterial blood gas measurement? See Chapter 16 of an unknown text (pdf)Chapter 16 of an unknown text
Imaging
Comment on the xray No date, no patient or projection information Poor reproduction (low resolution, low contrast) Good inflation and exposure Large opacity around right hilum Mass? Enlarged nodes? Tracheal deviation? Diffuse effusion? Heart border looks fuzzy Right lung and lower left lung are diffusely shadowy
More history A more detailed history is taken from his wife. Lost 5 kg over the past year, Dry cough Shortness of breath Headaches for some months. What diagnosis is most likely and what specific questions should be asked? How would you explain the neurological symptoms? To support the working diagnosis what further symptoms and signs should be sought specifically? List and justify further investigations that should be done at this point?