CASE PRESENTATION ON SEPTIC

ENCEPHALOPATHY

-D ASWIN
PHARM D INTERN
 SUBJECTIVE EVIDENCE

PATIENT DEMOGRAPHICS

 MRD NO: 2545697

 Age/Sex: 84/M
 Dept: General Medicine
 Date of admission:11/03/2023
 Date of discharge: 18/03/2023
 Reason for admission : c/o altered behavior
 FINDINGS:
 HISTORY OF PRESENT ILLNESS:
• An 84 year old male patient was apparently normal 4 days back and
was brought in by bystanders with complaints of altered
sleep,increased agitation, irrelevant talk and disorientation since 4-
5 days. Recently bystanders also gave history of patient harming
other. There is no h/o of trauma, seizures, slurring of speech ,
deviation of angle of mouth, substance abuse, blurred vision, bowel
or bladder incontinence, drug intake. No history of vomiting, loose
stools , chest pain, palpitations or breathlessness.
PAST HISTORY
 COPD
 Systemic hypertension
• PAST MEDICATION HISTORY:
DRUG GENERIC NAME DOSE Route FREQUENCY

TAB.AMLONG AMLODIPINE 5 mg PO 1-0-0

MDI FORACORT with FORMOTEROL-6 mcg 200 mcg(2 puffs) Inhalation 1-0-1
SPACER BUDESONIDE-400 mcg
FAMILY HISTORY: Hypertension
Diabetes
Heart disease
ALLERGIES: Nil
PERSONAL HISTORY
Appetite:Normal
Bowel habit:Normal
Urination:Normal
Sleep:Altered
 Objective evidence:
INTENSIVE MONITORING CHART
DATE TIME HEART RATE RESPIRATORY BLOOD TEMPERATUR
RATE PRESSURE E
12/03/23 10 am 84 22 130/70 97.4
12pm 80 20 110/70
13/03/23 6 am 76 20 100/70 98.2
10 am 74 20 150/70
4 pm 70 20 140/90
14/03/23 6 am 72 20 150/70 99
10 am 77 20 140/90
4 pm 84 22 110/70 98.4
15/03/23 6am 84 20 140/90 97.8
6 am 88 20 112/72 98.6
 12 pm 80 20 110/70 99
4 pm 72 22 140/90 97.8
10 pm 73 20 110/70 94.6
16/03/23 6am 82 20 130/70 98
17/03/23 6 am 84 20 100/70 98.6
18/03/23 6 am 86 20 130/70 97
NORMAL 60-100 12-20 120/80 97-99ᴼF
RANGE beats/min breaths/min mmHg
 HAEMATOLOGY:
DATE 13/03 14/03 15/03 NORMAL
RANGE

HAEMOGL 15.3 14.7 15.3 12 -15g/dL

OBIN

RED CELL 4.77 4.75 4.83 3.8 – 4.8

COUNT M/uL

P.C.V 44.8 46.1 45.1 42-52%

PLATELET 121 114 125 150 – 400

S K/uL
 TOTAL LEUCOCYTE COUNT:
DATE 13/03 14/03 15/03

NEUTROPHILS 69.6 68.2 66.6

LYMPHOCYTES 14.1 15.2 15.1

EOSINIPHILS 0.742 1.02 1.29

ESR

CRP 43.10 26.15

 BIOCHEMISTRY
13/03 14/03 15/03 NORMAL
VALUES
UREA 27.4 21.9 19.1 18-55 mg/dL

SER. CREATININE 0.77 0.69 0.72 0.7- 1.4 mg/dL

TOTAL BILIRUBIN 0.0 – 1.1 mg /dL

S.G.O.T 5 – 40 units/L

S.G.P.T 7 – 56 units/L

ALK. 44- 147 IU/L

PHOSPHATASE

TOTAL PROTEINS 6 – 8.3 g/dL

SER. ALBUMIN 3.5 – 5 g/dL

SER.GLOBULIN 2 – 3.5 g/dL

 ELECTROLYTES
13/03 14/03 15/03 NORMAL
RANGE
SODIUM 140 139 137.6 135-145
mEq/L

POTASSIU 3.9 3.6 3.8 3.6-5.2

M mmol/L

11/03/23
HbA1C 6.9
 GRBS CHART
12/03 7 pm 99
13/03 7 am 94
7 pm 98
14/03 8 am 104
1 pm 86
7 pm 98
15/03 7 am 103
6 pm 150
16/03 7 pm 165
17/03 6 am 143
18/03 6 am 122
 OTHER INVESTIGATIONS
 MRI BRAIN(PLAIN & CONTRAST)
Clinical information:85 yr old male with complaints of altered sensorium and fever(4
days)
IV contrast was given
Age related neuroparenchymal changes are noted
Focal areas of T2 FLAIR hyperintensities suggestive of chronic small vessel ischemic
changes
 CT Chest Contrast
Emphysema with fibrotic changes localised and restricted to apical segment with
relative sparing of bases.
Pleural and fissural thickening noted.
 USG Abdomen:Mild fatty liver
 Blood culture:No growth
 Urine routine showed 25-30 pus cells and numerous RBC’S.
 Assessment
The patient was diagnosed to have Septic encephalopathy
Type 2 Diabetes Mellitus
Urinary tract infection
 DISEASE DESCRIPTION
SEPTIC ENCEPHALOPATHY
Septic encephalopathy can be defined as a diffuse brain dysfunction
occurring in a patient with sepsis without evidence of an
intracranial infection and/or without conditions unrelated to the
infectious process that would significantly alter brain function.
SIGNS AND SYMPTOMS
• Disturbances of consciousness
• Impaired cognitive function
• Personality changes
• Lack of concentration
• Depressive symptoms
PATHOPHYSIOLOGY
• Disseminated cerebral microabscesses
Infecting organisms and /or their toxins do not directly cause encephalopathy
• Systemic inflammation resulting from infection or other causes action of
inflammatory mediators on the brain,cytotoxic response of brain cells.
• Sepsis activate a variety of inflammatory cascade
Inflammatory effector cell-neutrophil,macrophage,endothelial cell etc
Inflammatory mediators-Cytokines,lipid products,complement etc
• Free radicals- damage RBC and limit oxygen delivery to brain.
• Inflammatory mediators
Impair mitochondrial function and oxygen extraction by brain
• Destroy BBB
• Ultimately,extensive neuronal injury.
Treatment
 MEDICATION CHART
DRUG GN DOSE
MM ROUT
E
FREQ 11/
03
12/
03
13
/0
3
14
/0
3
15
/0
3
16/
03
17
/0
3
18/
03

INJ CEFTRIAXONE 2g IV STAT

CEFTRIAXONE +

INJ CEFTRIAXONE 2g IV 1-0-1 + +

CEFTRIAXONE

INJ CEFTRIAXONE 2g IV 1-0-0 + + + + +

CEFTRIAXONE

TAB.CLARITHR CLARITHROMYCIN 500 mg PO 1-0-1 + + + + +

OMYCIN

CANDID ORAL CLOTRIMAZOLE L/A 1-1-1 + + +

PAINT

SYRUP SODIUM PICOSULPHATE – 3.33 15 ml PO 1-0-1 + + + +

CREMAFFIN mg
PLUS LIQUID PARAFFIN-1.25 ml
MILK OF MAGNESIA-3.75 ml
DRUG GN DOSE ROUTE FREQ 11/0 12/0 13/0 14/0 15/0 16/0 17/0 18/0
3 3 3 3 3 3 3

INJ HYDROCORT 50 mg IV STAT +

HYDROCORT ISONE

NEB DUOLIN LEVOSALBUT 2.5 ml NEB 1-1-1-1 + + +

AMOL &
IPRATROPIU
M

SALINE PO 1-1-1 + + +
WASHES OF
MOUTH AFTER
FOOD INTAKE
INJ HYDROCORT 50 mg IV 1-0-1 + + +
HYDROCORT ISONE

TAB.THIAMINE THIAMINE 100 mg PO 1-0-0 +

DRUG GN DOSE ROUTE FREQ 11/03 12/03 13/03 14/0 15/03 16/03 17/03 18/03
3

TAB.QUETIAPINE QUETIAPINE 12.5 mg PO 0-0-1 + + +

TAB.HALOPERIDOL HALOPERIDOL 0.25 mg PO 1-0-1 + +

INJ RENERVE PLUS PYRIDOXINE-100 mg 1 amp IV 1-0-0 + + + + + + +

METHYLCOBALAMINE
-1000 mcg
NICOTINAMIDE-100
mg
INJ THIAMINE THIAMINE 100 mg IV 1-1-1 + + + + + +

INJ BRONAC N ACETYLCYSTEINE 600 mg IV 1-1-1 +

INJ PAN PANTOPRAZOLE 40 mg IV 1-0-0 + + + + + + + +

DRUG GN DOSE ROUTE FREQ 11/0 12/ 13/ 14/ 15/ 16 17/ 18/
3 03 03 03 03 /0 03 03
3

TAB.AMLONG AMLODIPIN 5 mg PO ½-0-0 + + + + + + + +

E
TAB.PULMOCL ACEBROPHY 1 tab PO 1-0-1 + + + + + + + +
EAR LLINE-100
mg
ACETYL
CYSTEINE-
600mg
NEB BUDESONID NEB 1-0-1 + + + + + + +
BUDECORT E

TAB.MONTAIR MONTELUK 1 tab PO 0-0-1 + + + + + + +

FX AST-10 mg
FEXOFENAD
INE-120 mg
IVF DNS DEXTROSE 1 pint IV 100 +
NORMAL ml/hr
SALINE
 PROGRESS NOTES
12/03/23
Patient reviewed
c/o altered behaviour and fever
Breathing difficulty
Plan for culture urine
Ceftriaxone started
13/03/2023
Patient reviewed
Ceftriaxone continued
Plan for MRI brain
14/03/2023
Patient reviewed
Vitals stable
c/o constipation
Alert and conscious
No fever spikes
Cough+
Sensorium improved
Plan:HRCT Chest Contrast
15/03/23
Patient reviewed
No fever spikes
Sensorium improved
Cough +
Continue IV antibiotics
16/03/23
Patient reviewed
Cough decreased
17/03/23
Patient reviewed
Vitals stable
No fresh complaints
Plan:USG Abdomen
18/03/23
Patient reviewed
Vitals stable
Plan:Discharge
 DISCHARGE MEDICATION
DRUG GN DOSE ROUTE FREQUENCY

TAB.CEFIXIME CEFIXIME 200 mg PO 1-0-1 for 1 week & stop

TAB.PAN PANTOPRAZOLE 40 mg PO 1-0-0 for 1 week

CANDID MOUTH PAINT CLOTRIMAZOLE L/A 1-1-1 for 10 days & SOS

TAB WYSOLONE PREDNISOLONE 10 mg PO 1-0-0*3 days

5 mg PO 1-0-0*3 days & stop

TAB.PULMOCLEAR ACEBROPHYLLINE-100 1 tab PO 1-0-1* 3 days

mg
ACETYL CYSTEINE-600mg

TAB MONTAIR FX MONTELUKAST-10 mg 1 tab PO 0-0-1 * 3 days

FEXOFENADINE-120 mg
MDI FORACORT with FORMOTEROL-6 mcg 200 mcg(2 puffs) INHALATION 1-0-1* 3 days & SOS
SPACER BUDESONIDE-400 mcg
TAB.AMLONG AMLODIPINE 2.5 mg PO 1-0-0

TAB.METFORMIN METFORMIN 500 mg PO 1-0-0

CAP.RENERVE PLUS 1 CAP PO 1-0-0

TAB.THIAMINE THIAMINE 100 mg PO 1-0-0
SYRUP SODIUM 15 ml PO 0-0-1
CREMAFFIN PICOSULPHATE –
PLUS 3.33 mg
LIQUID
PARAFFIN-1.25
ml
MILK OF
MAGNESIA-3.75
ml
 PATIENT COUNSELLING
DISEASE RELATED:
• Stay up to date on vaccines , including those for flu and pneumococcal disease.
• Avoid spending time around people who are sick.
• Drink plenty of clear fluids and rest.
• Vitamin C may help boost your immune system.
• Over-the-counter pain relievers such as acetaminophen and ibuprofen can be
helpful for fevers and to ease any aches.
• Wear face masks or coverings.
• Wash your hands often for at least 20 seconds.
• Avoid large groups of people.
• Be diligent about taking oral and inhaled medications and performing mucus
clearence techniques daily.
DRUG RELATED

 Talk to your doctor right away if you have more than one of these
symptoms while using Prednisolone:blurred
vision,dizziness,irregular heartbeat etc.
 Pantoprazole should be taken 30 mins before food.
 Check with doctor if you have serious skin reactions like
blistering,peeling or loosening of skin etc while using
clarithromycin.
 Maintain good oral hygiene while on treatment with inhaler.
 Check with doctor if you have pain or tenderness in the upper
stomach,pale stools,dark urine,loss of appetite etc.
• INHALER COUNSELLING
To use an inhaler with spacer , follow the directions below:
• Put the inhaler into the spacer and shake for 5 seconds
• Breath out a normal breath
• Close your lips around the spacer’s mouthpiece.
• Press down on the canister
• Breath in deeply and slowly and hold your breath for 5 to 10
seconds.Breath out away from the spacer.
• If you are supposed to take 2 puffs of your inhaler,wait 15 to 30
seconds before you take the second puff.shake the inhaler again
before the second puff.
 LIFESTYLE MODIFICATIONS
• Drink enough fluids to stay well hydrated.
• Stop smoking.
• Exercise regularly.
• Limit cholesterol.
• Diabetic diet:
Include more non starchy vegetables such as broccoli ,spinach and green beans.
Include fewer added sugars and refined grains such as white bread,rice,and pasta with
less than 2 grams of fiber per saving.
Focus on whole foods instead of highly processed foods as much as possible.
Beta glucans in oats and barley prevent blood glucose levels from increasing after the
intake of food.
Best choices are beans,dark green leafy vegetables,citrus fruits,tomatoes etc
Avoid full fat diary products,dried fruits,higher fat cuts of meat.
• Reduce salt intake.
THANK YOU