Causes of confusion in an Alcoholic Patient
Alcohol related causes :
Alcohol overdose / intoxication
Acute alcohol withdrawal
Delirium tremens
Wernickes encephalopathy
Acute on chronic liver failure :
Hypoglycemia
Hepatic encephalopathy
Cerebral / CNS causes :
Sub dural haematoma
Post ictal
Other causes
Sepsis
Hypothermia
Systemic diseases
HYPERCALCEMIA : SIGNS & SYMPTOMS , COMPLICATIONS , INVESTIGATIONS & MANAGEMENT
Signs and symptoms of hypercalcemia
These range from nonexistent to severe. Treatment depends on the cause.
Symptoms
There maybe no symptoms if hypercalcemia is mild.
More-severe cases produce signs and symptoms related to the parts of the body affected by the high calcium levels in the blood.
Examples include:
Kidneys.
Excess calcium makes kidneys work harder to filter it.
This can cause excessive thirst and frequent urination.
Digestive system.
Hypercalcemia can cause stomach upset, nausea, vomiting and constipation.
Bones and muscles.
In most cases, the excess calcium in the blood comes from bone resorption. This causes weakness of bones. This can cause bone pain and muscle weakness.
Brain
Hypercalcemia can interfere with normal functioning of the brain resulting in confusion, lethargy and fatigue. It can also cause depression.
Heart
Rarely, severe hypercalcemia can interfere with heart function, causing palpitations and fainting, indications of cardiac arrhythmia, and other heart problems.
Complications
Hypercalcemia complications can include:
Osteoporosis
If bone resorption continues,this releases calcium into the blood, and can lead toosteoporosis, which could lead to bone fractures, spinal column curvature and loss of height.
Kidney stones
If urine contains too much calcium, crystals might form in kidneys. Over time, the crystals can combine to form kidney stones. Passing a stone can be extremely painful.
Kidney failure
Severe hypercalcemia can damage kidneys, limiting their ability to cleanse the blood and eliminate fluid.
Nervous system problems
Severe hypercalcemia can lead to confusion, dementia and coma, which can be fatal.
Abnormal heart rhythm (arrhythmia)
Hypercalcemia can affect the electrical impulses that regulate heartbeat, causing heart to beat irregularly.
Diagnosis
Because hypercalcemia can cause few, if any, signs or symptoms, it may go un noticed until routine blood tests reveal a high level of blood calcium.
Blood tests can also show if parathyroid hormone level is high, indicating that patient will have hyperparathyroidism.
To determine if hypercalcemia is caused by a disease such as cancer or sarcoidosis, imaging of bones or lungs may be needed
More Information can be obtained by
Chest X-rays
CT scan
Mammogram
Treatment
If your hypercalcemia is mild, watch and wait policy may be adopted, monitoring bones and kidneys over time to be sure they remain healthy.
For more severe hypercalcemia, medications or treatment of the underlying disease, including surgery may be considered.
Medications
Calcitonin (Miacalcin)
This hormone from salmon controls calcium levels in the blood. Mild nausea might be a side effect.
Calcimimetics
This type of drug can help control overactive parathyroid glands. Cinacalcet (Sensipar) has been approved for managing hypercalcemia.
Bisphosphonates
Intravenous osteoporosis drugs, which can quickly lower calcium levels, are often used to treat hypercalcemia due to cancer.
Risks associated with this treatment include breakdown (osteonecrosis) of the jaw and certain types of thigh fractures.
Denosumab
This drug is often used to treat people with cancer-caused hypercalcemia who don't respond well to bisphosphonates.
Prednisone
Ifhypercalcemia is caused by high levels of vitamin D, short-term use of steroid pills such as prednisone are usually helpful.
IV fluids and diuretics.
Extremely high calcium levels can be a medical emergency that might need hospitalization for treatment with IV fluids and diuretics to promptly lower the calcium level to prevent heart rhythm problems or damage to the nervous system.
Surgical and other procedures
Problems associated with overactive parathyroid glands often can be cured by surgery to remove the tissue that's causing the problem.
In many cases, only one of a person's four parathyroid glands is affected.
A special scanning test uses an injection of a small dose of radioactive material to pinpoint the gland or glands that aren't working properly.
HYPERCALCEMIA
Hypercalcemia is a condition in which the calcium level in the blood is above normal.
Too much calcium in blood can weaken bones, create kidney stones, and interfere with normal heart and brain work.
MECHANISM OF HYPERCACEMIA
Hypercalcemia is usually a result of overactive parathyroid glands. These four tiny glands are situated in the neck, near the thyroid gland.
Other causes of hypercalcemia include cancer, certain other medical disorders, some medications, and taking too much of calcium and vitamin D supplements.
Besides building strong bones and teeth, calcium helps muscles contract and nerves transmit signals. Normally, if there isn't enough calcium in blood, the parathyroid glands secrete a hormone that triggers:
Bones to release calcium into the blood
The digestive tract to absorb more calcium
The kidneys excrete less calcium and activate more vitamin D, which plays a vital role in calcium absorption
This delicate balance between too little calcium in blood and hypercalcemia can be disrupted by a variety of factors.
CAUSES
Hypercalcemia is caused by:
Overactive parathyroid glands (hyperparathyroidism)
This most common cause of hypercalcemia can stem from a small, noncancerous (benign) tumor or enlargement of one or more of the four parathyroid glands.
Cancer
Lung cancer and breast cancer, as well as some blood cancers, can increase risk of hypercalcemia. Spread of cancer (metastasis) to bones also increases risk.
Other diseases
Certain diseases, such as tuberculosis and sarcoidosis, can raise blood levels of vitamin D, which stimulates the digestive tract to absorb more calcium.
Hereditary factors
A rare genetic disorder known as familial hypocalciuric hypercalcemia causes an increase of calcium in the blood because of faulty calcium receptors in body.
Immobility
People who have a condition that causes them to spend a lot of time sitting or lying down can develop hypercalcemia. Over time, bones that don't bear weight release calcium into the blood.
Severe Dehydration
A common cause of mild or transient hypercalcemia is dehydration. Having less fluid in blood causes a rise in calcium concentrations.
Medications
Certain drugs — such as lithium, used to treat bipolar disorder — might increase the release of parathyroid hormone.
Supplements
Taking excessive amounts of calcium or vitamin D supplements over time can raise calcium levels in your blood above normal.
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Pneumococcal pneumonia presents classically as lobar or segmental consolidation.
Multiple , non-contiguous and sometimes bilateral segments may be affected with multilobar involvement being a poor prognostic factor.
The absence of an air bronchogram within an area of consolidation suggests exudate or pus filling the conducting airways aside from Streptococcus pneumonia , organisms commonly responsible for this appearance include Staphylococcus and Gram negative organisms.
Early cavitation in an area of consolidation is typical ofstaphylococcal infection but consider Gram negative organism such as Klebsiella and donot forget Tuberculosis.
Also consider Aspiration pneumonia or proximal bronchial obstruction eg due to carcinoma or a foreign body.
A variety of Radiographic patterns are described in Mycoplasma pneumonia & in Lgionnaire”s disease.
The presence of pleural fluid is suggestive of bacterial aetiology and a diagnostic tap should be performed if this is anything more than trivial in size.
In pneumococcal pneumonia the radiograph maybe normal at presentation even in the presence of a classical history and signs of consolidation on examination only to become abnormal over the next few hours.
Routine blood tests :
Full blood count
Anemia will compound impared tissue oxygen delivery and white cell count is likely to be elevated.
However a patient with overwhelming sepsis may have a normal white cell count.
Electrolytes and Renal function
Uremia is a bad prognostic sign in pneumonia
Hyponatremia is another non-specific marker of severity of infection and is also a particular feature of Legionaires disease.
Liver function Tests :
Derangement of liver enzymes maybe seen in any severe sepsis but transient hepatitis is seen as a part of multisystem involvement in atypical infections such as Legionairres disease.
Also inflammatory markers such as CRP is a more sensitive marker of severity of pneumonia than an increased temperature or a white cell count.
Microbiological Tests :
Sputum microscopy and culture
If sputum is obtainable,it is important to send early in infection
And do a sputum for AFB test / Acid fast bacilli
Blood cultures
Urinary assays of specific antigens : pneumococcal antigen and Legionella antigen
Serological testing : Send acute and convalescent titres for atypical serology
Pleural fluid if there is significant effusion.
Management
General management and resuscitation if needed.
CURB -65 score
Assessment using CURB-65 is vital as a prognostic indicator
Confusion
Mini mental scale Examination < 8
Or new disorientation in person , place and time
Urea > 7 mmol/l
Respiratory rate > 30 / minute
BP systolic < 90 mm Hg or
Diastolic < 60 mmHg
Age > 65 yrs
Score 1 point for each feature present.
A score of 3 – 5 suggests severe pneumonia,
Antibiotics :
Antibiotics should be given without delay with the choice guarded by the BTS guidelines
And / or local knowledge of of the pathogens commonly implicated.
Always consult local prescribing policies in addition to obtaining microbiological advice as necessary.
CURB-65 score 1 or 2 in the moderately sick patient ,oral amoxicillin and a macrolide should be given.
In those patients allergic to penicillin, a fluoroquinolone should be given ie levofloxacin
CURB 65 score 3 or more
In the more severely ill patient , co-amoxiclav or a third generation cephalosporin should be given intravenously in conjunction with a macrolide.
In patients who are penicillin allergic, an intravenous fluoroquinolone in addition to a macrolide shoukd be considered.
If Legionaires disease is considered, then intravenous Erythromycin 1 Gram every 6 hours should be considered.
If there is any suggestion of preceding influenza , consider adding a specific antistaphylococcal antibiotic eg Fluclocloxacillin.
If Gram negative infection or aspiration is suspected , then a 3rd Generation Cephalosporin is the antibiotic of choice.
Pneumonia refers to infection & inflammation of the lung tissue / parenchyma.
Pneumonia is an infection
that inflames the air sacs in one or both lungs. The air sacs may fill with
fluid or pus (purulent material), causing cough with phlegm or pus, fever,
chills, and difficulty breathing.
A variety of organisms,
including bacteria, viruses and fungi, can cause pneumonia.
Pneumonia can range in seriousness from mild to
life-threatening.
It is most serious for
infants and young children, people older than age 65, and people with health
problems or weakened immune systems.
Symptoms
The signs and symptoms of
pneumonia vary from mild to severe, depending on factors such as the type of
germ causing the infection, and your age and overall health.
Mild signs and symptoms often
are similar to those of a cold or flu, but they last longer.
Signs and symptoms of pneumonia may include:
Chest pain when you breathe
or cough
Confusion or changes in
mental awareness (in adults age 65 and older)
Cough, which may produce
phlegm
Fatigue
Fever, sweating and shaking
chills
Lower than normal body
temperature (in adults older than age 65 and people with weak immune systems)
Nausea, vomiting or diarrhea
Shortness of breath
Products & Services
Clinical features of
pneumonia
Fever
Cough
Shortness of breath
Malaise
Breathlessness
Confusion
Fever : is usually high grade upto 38.5 C
Breathlessness is a characteristic feature of pneumonia.
It indicates a ventilation perfusion mis match as seen in
pneumonic consolidation.
Cough :
Does the patient have a cough?
If yes,is it dry , productive or purulent?
Does the patient normally have a cough and produce sputum?
In a patient with Normal lungs, a dry cough is suggestive of
pneumonia of any sort.
A purulent cough is suggestive of an underlying bacterial
infection.
A brownish red / rusty colored cough is suggestive of
pneumococcal infection.
Chest pain could be due to soreness from coughing or it may
be pleuritic due to which is more common in bacterial than non-bacterial
infection.
When did the illness
start ?
Bacterial pneumonias have a small prodrome as compared to non-bacterial
infections
Eg Mycoplasma will have a longer prodromal phase.
Presence of confusion indicates the pneumonia is severe.
But note that classic symptoms and signs of pneumonia are
less likely in the elderly and hence confusion may be the main presenting
symptoms and only diagnostic clue.
Are there any other likely Diagnosis ?
Other common causes
of acute presentation with breathlessness include :
Pulmonary oedema
Pulmonary embolism
Are there any clinical features that suggest these as
possible cause ?
Patients with atypical pneumonias may have GI symptoms.
Relevant Past Medical
history
A detailed Past Medical history is required
But particular emphasis should be on the following ;
Ask if the patient has a previous history of
COPD / Chronic Obstructive Pulmonary Disease
Bronchiectasis or a long standing lung problem
Smoking history
Alcohol History
Alcoholism can lead to recurrent Aspiration Pneumonias as
well as pneumococcal and Gram negative and atypical infections.
Also determine if the patient has suffered from Alcohol
withdrawal if admitted to the hospital.
Pets : are there any parrots or budgies at home of patient ?
Is the patient immunosuppressed ?
HYPONATREMIA : RISK FACTORS , CAUSES, INVESTIGATIONS ,COMPLICATIONS & MANAGEMENT
RISK FACTORS OF HYPONATREMIA
The following factors may increase your risk of hyponatremia:
Age. Older adults may have more contributing factors for hyponatremia, including age-related changes, taking certain medications and a greater likelihood of developing a chronic disease that alters the body's sodium balance.
Certain drugs. Medications that increase your risk of hyponatremia include thiazide diuretics as well as some antidepressants and pain medications. In addition, the recreational drug Ecstasy has been linked to fatal cases of hyponatremia.
Conditions that decrease your body's water excretion. Medical conditions that may increase your risk of hyponatremia include kidney disease, syndrome of inappropriate anti-diuretic hormone (SIADH) and heart failure, among others.
Intensive physical activities. People who drink too much water while taking part in marathons, ultramarathons, triathlons and other long-distance, high-intensity activities are at an increased risk of hyponatremia.
SIADH
SYNDROME OF INAPPROPRIATE ADH SECRETION
Syndrome of inappropriate antidiuretic hormone secretion occurs when excessive levels of antidiuretic hormones (hormones that help the kidneys, and body, conserve the correct amount of water) are produced. The syndrome causes the body to retain water and certain levels of electrolytes in the blood to fall (such as sodium).
CAUSES OF SIADH
SYNDROME OF INAPPROPRIATE ADH SECRETION
SIADH tends to occur in people with heart failure or people with a diseased hypothalamus (the part of the brain that works directly with the pituitary gland to produce hormones). In other cases, a certain cancer (elsewhere in the body) may produce the antidiuretic hormone, especially certain lung cancers. Other causes may include the following:
Meningitis (inflammation of the meninges, the membranes that cover the brain and spinal cord)
CAUSES OF SIADH
SYNDROME OF INAPPROPRIATE ADH SECRETION
Encephalitis (inflammation of the brain)
Brain tumors
Psychosis
Lung diseases
Head trauma
Guillain-Barré syndrome (a reversible condition that affects the nerves in the body. GBS can result in muscle weakness, pain, and even temporary paralysis of the facial, chest, and leg muscles. Paralysis of the chest muscles can lead to breathing problems.)
Certain medications
Damage to the hypothalamus or pituitary gland during surgery
Thyroid or parathyroid hormone deficiencies
HIV
Hereditary causes
INVESTIGATIONS FOR DETECTING CAUSE OF HYPONATREMIA
URINARY SODIUM CONCENTRATION is useful for disinguishing between renal and extrarenal hypovolemic hyponatremia and hypervolemic hyponatremia.
PAIRED URINE AND PLASMA OSMOLALITIES should be sent to exclude possibilty of SIADH.
CT Head to exclude any sub dural haematoma / head injury to exclude SIADH as a cause of hyponatremia.
COMPLICATIONS OF HYPONATREMIA
In chronic hyponatremia, sodium levels drop gradually over 48 hours or longer — and symptoms and complications are typically more moderate.
In acute hyponatremia, sodium levels drop rapidly — resulting in potentially dangerous effects, such as rapid brain swelling, which can result in a coma and death.
Premenopausal women appear to be at the greatest risk of hyponatremia-related brain damage. This may be related to the effect of women's sex hormones on the body's ability to balance sodium levels.
PREVENTION OF HYPONATREMIA
Treat associated conditions. Getting treatment for conditions that contribute to hyponatremia, such as adrenal gland insufficiency, can help prevent low blood sodium.
Educate yourself. If you have a medical condition that increases your risk of hyponatremia or you take diuretic medications, be aware of the signs and symptoms of low blood sodium. Always talk with your doctor about the risks of a new medication.
Take precautions during high-intensity activities. Athletes should drink only as much fluid as they lose due to sweating during a race. Thirst is generally a good guide to how much water or other fluids you need.
MANAGEMENT OF HYPONATREMIA
Hyponatremia treatment is aimed at addressing the underlying cause, if possible.
If you have moderate, chronic hyponatremia due to your diet, diuretics or drinking too much water, your doctor may recommend temporarily cutting back on fluids. He or she may also suggest adjusting your diuretic use to increase the level of sodium in your blood.
If you have severe, acute hyponatremia, you'll need more-aggressive treatment. Options include:
TREATMENT OF HYPONATREMIA
Intravenous fluids. Your doctor may recommend IV sodium solution to slowly raise the sodium levels in your blood. This requires a stay in the hospital for frequent monitoring of sodium levels as too rapid of a correction is dangerous.
Medications. You may take medications to manage the signs and symptoms of hyponatremia, such as headaches, nausea and seizures.
1.8 % saline infused at rate of ( 1.7 * patients weight in Kg) ml/hr or 3% saline infused at rate of (1.0 * pts weight in Kg )/ml/hr will increase serum sodium concentration by 1 mmol/hour.
Aim in early phases is to increase serum sodium concentration by 1 mmol/hour but no more than 15 – 20 mmol/hour over 48 hour.
TREATMENT OF SIADH
Specific treatment for SIADH will be determined by your doctor based on:
Your age, overall health, and medical history
Extent of the disease
Your tolerance for specific medications, procedures, or therapies
Expectations for the course of the disease
The most commonly prescribed treatment for SIADH is fluid and water restriction. If the condition is chronic, fluid restriction may need to be permanent. Treatment may also include:
Certain medications that inhibit the action of ADH (also called vasopressin)
Surgical removal of a tumor that is producing ADH
Other medicines to help regulate body fluid volume
