QUIZ: Obsession? *solved*

Wednesday, 23 December 2009 19:14

26 yo male arrived via an ambulance from his work (building site worker) with typical acute abdomen symptoms. Fast diagnostic and diagnosis: perforated gastric ulcer. Patient underwent an operation and was transported to a ward. No complications.

On third day he started exhibited strange behaviour.
He is waking up in the middle of the night. No logical contact. He is very excited and his arms tremble. He behaves offensively towards the doctors and sometimes falls down on the floor with trembles all over the body.
Pressure 150/95, HR 120/min

Quiz questions:
1. What's the most probable diagnosis?
2. What are the procedures and treatment? Be careful - one bad move could be tragic.

Comments

0 #1 dave 2009-12-24 11:52

Postoperative brain edema?

Consciousness disorders, epileptic syndroms, everything fits...

0 #2 MMader 2009-12-24 14:13

How would you confirm it?

Does every convultion needs to be an epileptic attack?

0 #3 dave 2009-12-24 15:18

CT/MRI of a head, what about electrolytes? Whats the body temperature?

Are these episodes of loosing consciousness happens only at night?

0 #4 xray1815 2009-12-25 02:11

What about after alcohol delirium? He has gaster ulcer disease and he is working in group which frequently abuse alcohol in most countries. So far it fits.

Treatment: He needs to be transferred to a psychiatric ward.
I suggest: Tisercin 25mg or fenactil 25 mg i.v.
Relanium - from 5 to 20mg i.v. or midanium 2-5 mg. i.v.

We need to check ionogram and supplement electrolytes if there is a need.

Patient needs to be controlled during his transport in an ambulance - suicides attempts or other activities. We could fasten his seat belts if he would become aggressive.

0 #5 MMader 2009-12-25 13:15

Xray - you ideas are very good but the procedures aren't perfect.

1. The patient will not be admitted to a psychiatric ward. He will come back in the same ambulance with note of egzogenic consciousness disorders. The transport itself is a danger for this patient.

2. There is something important missing in treatment. Maybe it's not so important in curing but in prevention. There is a big chance that patient's family will file a lawsuit and will get a huge settlement.

+1 #6 xray1815 2009-12-25 14:11

1. We can always try to call the ward and try to get a place for our patient. If we don't succeed we are going to try our best where we are.

2. You are right - thiamine is missing - for the prevention of Korsakov syndrome.

+1 #7 MMader 2010-01-04 17:43

Case solved.

Few word of commentary: the case above isn't rare. In lots of countries there is big amount of people who drink a lot. Sooner or later it could happens that such person will go to hospital and after a few day abstinence we could have such a delirium.

1. It is a state of life endangerment.
2. We can't transport this patient - needs to be treated on ward where he is admitted.
3. Sometimes patient needs to be immobilized.
4. Can't forget about Vitamin B1 - there is a risk of neurological threats (in example Korsakov syndrome). Consequences are bad.

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