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 pain5 BVRinappropriate words3 BERspontenous4 Total 12/15

Physical exam

Meningeal signs No neck stiffness No kerning sign No brudzinskiPupils Equal reactive

Physical exam Motor Tone:normal and symmetrical Power :could not be assess Reflex :normal and symmetrical Sensory Pain,touch,vibration,postion :could not be

assess Deep pain: present and symmetrical Babinski :down going

Physical exam

Cerebullar exam&Cranial nerves : could not be assess HEET:no palor, no jaundice, no cynosis, no LAP,no rasid

JVP,no depress fracture, no raccoon eyes, no battle’s sign, no palpable thyroid gland.

Chest :GBAE,inspiratory rhonchi and expiratory crepitation on RLLL.

Heart:S1& S2 irregular irregularity , no murmur Abdomen:soft,no HSM, no palpable kidneys,no ascitis,

BS + Ext: PPP, no LLL

Differential DiagnosisCNS Causes 1- Hypertensive encephalopathy R/O with BP140/80 at presentation 2- CVA 3-epi or sub dural hematoma 4-SAH Brain MRI: no new ischemia, old ischemic

lesions and atrophy, no mass 5- CNS infection 6-seizures

Endocrino.Causes

1-NKDC2-DKA3-hypoglycemia

R/O HGT of 190 U/A -ve keton4-hypothyroidism TSH 0.24,FT3 1.95,FT41.17

Drugs or suicide

No enough clues

sepsis

1-Pneumoina WBC-13.8 N 90%-L 5.3% CRP 5.23 PH 7.43,PCO2 43.5,PO2 68.8,sat 94.6% CXRnormal 4days laterRLLLinfltarateaspiration

sepsis

2-Urosepsis U/ARBC 68 WBC 180 Epith +++ Urine Cxno growth Blood CXStaph.Epi in 1 bottle

Cardiac Cause

Myocardial infarction ECG Slow rate atrial fibrillation troponin 0.168 CPK 694 CK-MB 29 Serial troponin 0.120.0950.084

metabolic Causes

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

Metabolic Causes

2-Uremic encephalopathy RFT Urea 56 crea1.16 K 3 Cl 101 Hco3 32.8

Metabolic causes

3-Hypernatremia or Hyponatremia R/O Na 141

Metabolic Causes

4-Hypercalcemia Ca 14.8 Ph 1.4 Alb 4.8

Hypercalcemia

Hyperparathyroidism Bone metastasis 1-MMmale,age,ALP afebrile,Hb15,ESR11 2-prostate caSPA=3.77 3-lung ca 4-thyroid ca 5-kidney ca

Hypercalcemia Thiazide Lithium Vit A or D toxicity Sarcoidosis and other granulomatous

diseases Milk-alkali syndrome Immobility Familial hypocalciuric hypercalcemia hyperthyroidism

hyperparthyroidism

PTH 492.5(15-65)adenoma vs malignancy Neck US enlarge R.inf.parathyroid gland

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.inf.gland resection PTH drop more than 80% 30 min after

resection BXAdenoma Pt improve dramatically and dischaged with Caltrate+1alfa(post-operative hypoca) Sintrom Captopril and nifedicor To be follow up as an out pt.

Symptoms and Signs of hyerCa

A symptomatic >12mg/dl >13mg/dlRF+ectopic soft-tissue calcification Renal: polyuria+thirst+stones GIT: anorexia,nausea,vomiting,constipation Neurologic:weakness,fatigue,confusion,stuporand comaECGshortened QT

Calcium metabolism

Treatment of hypercalcemia

1. According to cause2. According to ca level Mild hyperca<12mg/dlhydration More severe 13-15mg/dlmore agressive Life threatening>15mg/dlemergency

measure

Bisphosphonates High affinity to bone especially in area of

increase bone turnover powerful inhibitors of bone resorption

osteoclast Mechasim:1. Alter osteoclast proton pump function or

impair the relase of acid hydrolases2. Inhibite the differential of monocyte-

macrophage precursors into osteoclast3. Effect on osteoblast as well

Bisphosphonates

Duration of action:1-2d and last for 1 w 3rd generationzolendronate faster and last

longer Dose1-4mg IV over few min

calcitonin Mechanism:1. Inhibite osteoclast and bone resorption2. 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,SC or IM Q6-12h