New confusion- Encephalitis

A 42 year old comes to ED with complaints of headaches and progressive confusion. Please assess the patient

Answer

I would start by taking a focus history, specifically asking about the character of the headaches and the onset of the headaches, if it is a persistently, progressive Headache with red flag features I would be very concerned. I will try and get a collateral history from the next of kin regarding the confusion. I would also look for any focal neurological symptoms I will I’ll try and assess the background of the patient and take a detailed family history and social history. After this, I would do a focused A to E assessment.

Airway – I would ensure the airway is patent and if necessary insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct I would be really worried and seek the help of the critical care team after my assessment if there was a problem with the airway assessment.

Breathing – I would look at the observations specifically the oxygen saturation and the respiratory rate. If the patient is hypoxic or if the patient has an increased work of breathing I’ll start the patient on supplemental oxygen therapy. I would also get a PEFR and an ABG done for this patient to see what the ph, Po2 , pco2 and hcO3 and lactate. I would be very concerned if the HcO3 and PH are very low. I would also keep an eye out on the electrolytes on the blood gas that was done. I would also arrange a portable CXR for the patient

Circulation – I would look at the observations specifically the BP, heart rate and CRT. If there is evidence of hypotension or tachycardia I would give a fluid challenge to the patient to see if there is an adequate response. And if the patient remains hypotension despite the first fluid challenge I will give another fluid challenge and ensure the critical care team is aware of the patient. I would also ensure the patient has a working cannula and send basic bloods including septic screening. I would also request an ECG for the patient. I will also request a lying and standing blood pressure to look into the orthostatic hypotension.

Disability – I would check the patients blood glucose and capillary ketones, temperature and do a focused neurological assessment that includes GCS. Specifically if the GCS is less than 8 or if there is a focal neurological deficits I would be concerned and investigate this further.

Exposure – I would examine the patients abdomen and look for evidence of an intra-abdominal pathology.

Question

Patient mentions that she came back from a trip to Mexico a week back and has been getting a progressively worsening headache Associated with severe nausea, vomiting, and the headaches are worse in the morning. Her husband mentioned that she’s not herself and is getting more confused with day-to-day activities over the last five days.Her observations and VBG are unremarkable. You notice on examination that she has a subtle right sided weakness along with impaired attention and recall. What would you do next?

Answer

Given the acutely, progressive nature of these symptoms And the fact that she has a progressive headache with clear focal Neurological Signs, I would be concerned about a progressive encephalitic process and starting investigation for the same. I will follow the trust guidelines and empirically prescribe her antibiotics and antivirals for meningoencephalitis. And I’ll try and get an urgent CT scan of her head. I would Escalate this to my senior And aim to get a lumber puncture as soon as possible. I would also keep the family updated and ensure that they are aware of the clinical progress in the hospital.

Question

Her CT head Is unremarkable and her lumbar puncture is still Awaited, she has two witnessed tonic clonic seizures In the hospital. The nurse has requested you to review the patient now. What would you do next?

Answer

I would review the patient and get a description of the seizures from the witnesses. I would use the A to E approach and assess her. I would Discuss with my seniors And consider starting an Anti epileptic drug for her seizures. After this, I would ensure that she is nursed in a high dependency unit and the seizure chart is maintained.