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
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.