Metabolic encephalopathy

Marwan Y.Kattan PGY1

History 
A 80 y old male pt. known to be hypertensive

,living alone, admitted for altered level of consciousness.  Pt condition started the day preceding his admission as pt was complaining from generalized fatigue and weakness ,SBP was 200 and he has been advised to double his antihypertensive drug (thiazide).  Next day pt was found at the ground with altered level of consciousness and urinary incontinence.

History 
No preceding fever, no chills, no headache,

no photophobia,no N & V,no visual problem,no aura or abnormal movements.  No cough, no sputum ,no SOB.  No chest pain,no palpitation, no diaphoresis.  No flank pain, no dysuria, no hematuria.

History  No history of travel  No empty bottle or suicide note was found .

Past Medical History  HTN +  DM ±  No CRF  No liver cirrhosis or chronic liver disease  No malignancy  No psychiatric illness  No history of blood transfusion .

Past Surgical History  Nil .

Allergy  NKDA .

Social history  Non-smoker  Non-alcoholic  Non-IV drug user .

Medication  Esidrex 25mg 1 tab QD  No insulin or antidiabetic agents  No benzodiazepam or hypnotics .

Physical exam.  V/S  HR:60/min irregular irregularity  BP:140/80  RR:30/min  Temp 36 c .

Physical exam  Semi-conscious  Not alert  Disoriented to P-P-T  Elderly male  Looking ill  Good nutritional status  dehydrated .

Physical exam  GCS  BMR localizes pain 5  BVR inappropriate words 3  BER spontenous 4  Total 12/15 .

Physical exam  Meningeal signs  No neck stiffness  No kerning sign  No brudzinski  Pupils  Equal  reactive .

Physical exam Motor Tone:normal and symmetrical Power :could not be assess Reflex :normal and symmetrical Sensory Pain.vibration.postion :could not be assess  Deep pain: present and symmetrical  Babinski :down going       .touch.

no LAP. no battle¶s sign.no depress fracture.Physical exam  Cerebullar exam&Cranial nerves : could not be assess  HEET:no palor.no rasid     JVP. no jaundice. no raccoon eyes. no cynosis.no HSM. no LLL .no ascitis. no palpable kidneys. Heart:S1& S2 irregular irregularity . no murmur Abdomen:soft.inspiratory rhonchi and expiratory crepitation on RLLL. no palpable thyroid gland. BS + Ext: PPP. Chest :GBAE.

CNS infection  6-seizures       .Differential Diagnosis CNS Causes 1. old ischemic lesions and atrophy.CVA 3-epi or sub dural hematoma 4-SAH Brain MRI: no new ischemia.Hypertensive encephalopathy R/O with BP140/80 at presentation 2. no mass  5.

Endocrino.FT3 1.Causes 1-NKDC 2-DKA 3-hypoglycemia R/O HGT of 190 U/A -ve keton 4-hypothyroidism TSH 0.FT41.24.17 .95.

Drugs or suicide  No enough clues .

6% CXR normal 4days later RLLLinfltarate aspiration .23 PH 7.43.PO2 68.PCO2 43.3% CRP 5.sat 94.8 N 90%-L 5.sepsis       1-Pneumoina WBC-13.8.5.

Epi in 1 bottle .sepsis  2-Urosepsis  U/A RBC 68 WBC 180 Epith +++  Urine Cx no growth  Blood CX Staph.

168  CPK 694  CK-MB 29  Serial troponin 0.095 0.Cardiac Cause Myocardial infarction  ECG Slow rate atrial fibrillation  troponin 0.12 0.084 .

metabolic Causes 1-Hepatic encephalopathy  LFT  GOT 70  GPT 35  ALP 61  GGT 40 .

Metabolic Causes 2-Uremic encephalopathy  RFT  Urea 56  crea1.8 .16  K3  Cl 101  Hco3 32.

Metabolic causes  3-Hypernatremia or Hyponatremia  R/O Na 141 .

8  Ph 1.8 .4  Alb 4.Metabolic Causes  4-Hypercalcemia  Ca 14.

Hb15.ESR11 2-prostate ca SPA=3.77 3-lung ca 4-thyroid ca 5-kidney ca .age.ALP      afebrile.Hypercalcemia  Hyperparathyroidism  Bone metastasis  1-MM male.

Hypercalcemia Thiazide Lithium Vit A or D toxicity Sarcoidosis and other granulomatous diseases  Milk-alkali syndrome  Immobility  Familial hypocalciuric hypercalcemia  hyperthyroidism     .

parathyroid gland .hyperparthyroidism  PTH  492.inf.5(15-65) adenoma vs malignancy  Neck US  enlarge R.

mangement  Pt receive:  IV hydration+lasix+Miacalcic+Zometa  AB+Bronchodilator+steroids  nifedicor+captopril+IV nitrocine  Anticoagulation  KCL and sodium phosphate  Schedule for surgery .

mangement  Neck exploration with R.gland resection  PTH drop more than 80% 30 min after resection  BX Adenoma  Pt improve dramatically and dischaged with  Caltrate+1alfa(post-operative hypoca)  Sintrom  Captopril and nifedicor  To be follow up as an out pt. .inf.

nausea.confusion.fatigue.Symptoms and Signs of hyerCa  A symptomatic  >12mg/dl  >13mg/dl RF+ectopic soft-tissue calcification  Renal: polyuria+thirst+stones  GIT: anorexia.constipation  Neurologic:weakness.vomiting.stupor and coma ECG shortened QT .

Calcium metabolism .

According to ca level  Mild hyperca <12mg/dl hydration  More severe 13-15mg/dl more agressive  Life threatening >15mg/dl emergency measure . According to cause 2.Treatment of hypercalcemia 1.

3.Bisphosphonates  High affinity to bone especially in area of   1. 2. increase bone turnover powerful inhibitors of bone resorption osteoclast Mechasim: Alter osteoclast proton pump function or impair the relase of acid hydrolases Inhibite the differential of monocytemacrophage precursors into osteoclast Effect on osteoblast as well .

Bisphosphonates  Duration of action:1-2d and last for 1 w  3rd generation zolendronate faster and last longer  Dose 1-4mg IV over few min .

SC or IM Q6-12h .calcitonin  Mechanism: 1. Inhibite osteoclast and bone resorption 2. Increase urinary Ca excretion by inhibition of renal tubular Ca reabsorption  Duration of action: few hours  Minimal lowering of Ca  Dose:2-8 U/Kg IV.