A 26 year old lady presents from home confused with a low-grade fever. Her blood pressure is 160/100 mm Hg. She has no gross motor deficits. Ten days ago she had an emergency termination of pregnancy for an intrauterine death that was complicated by disseminated intravascular coagulation. She was 32 weeks gestation and had been on labetalol for a pregnancy-induced hypertension.
Her discharge medications included paracetamol, tramadol and a selective serotonin reuptake inhibitor. She has a 6-year history of uncomplicated Hepatitis C.
- 27.1. List the differential diagnoses for her confusion and temperature.
- 27.2. Outline your approach to establishing the diagnosis.
Answer and interpretation
27.1. List the differential diagnoses for her confusion and temperature.
- Pregnancy related:
— Eclampsia / preeclampsia / HELLP, Retained products with sepsis, Sheehan’s syndrome / pituitary apoplexy, Posterior reversible encephalopathy syndrome (PRES), Hypertensive encephalopathy
- Primary neurological:
— Infection (meningitis / encephalitis), cerebral venous thrombosis, seizure disorder, other cerebro-vascular
— Sodium (hypo/hyper), Glucose (hypo/hyper), Renal failure, Liver failure (HCV / Paracetamol / Antidepressants),
— Accidental / intentional overdose, drug reactions (serotonin syndrome) Infection: Uterine, intracranial, other (renal, chest etc)
27.2. Outline your approach to establishing the diagnosis.
- Collateral, Pregnancy issues, Ongoing blood loss, bleeding / bruising, drug ingestions, mood / affect, headaches
- BP, uterine size / discharge, oedema, meningism, neurological (tone, reflexes, symmetry), chronic liver disease
- FBC: Bleeding, platelets, WCC
- UEC: urea / creatinine, Na, Ca, glucose
- Coagulation: DIC, INR for CLD
- LFT / Ammonia: hepatic encephalopathy, drug reactions
- ABG: hypoxia / hypercardia
- Urinary drug screen / paracetamol level
- Sepsis Screen, CT head +/- LP