CASE71:DROWSINESS
History
A 72-year-old woman develops a chest infection and is treated at home with doxycycline
by her general practitioner (GP). She lives alone but one of her daughters, a retired nurse,
moves in to look after her. The patient has a long history of rheumatoid arthritis which is
still active and for which she has taken 7 mg of prednisolone daily for 9 years. She takes
paracetamol occasionally for joint pain. There is no other relevant past or family history.
When the GP visited he found the blood pressure to be 138/82 mmHg.
For 5 days since 2 days before starting the antibiotics she has been feverish, anorexic and
confined to bed. Her daughter has made her drink plenty of fluids. On the fifth day she
became drowsy and her daughter had increasing difficulty in rousing her, so she called an
ambulance to take her to the emergency department.
Examination
She is small (assessed as 50 kg) but there is no evidence of recent weight loss. Her temper-
ature is 38.8°C. She is drowsy and responds to commands, but will not answer simple ques-
tions. There is a global reduction in muscle tone but no focal neurological signs. Her pulse
is 118/min, blood pressure 104/68 mmHg and the jugular venous pressure is not raised.
There is no ankle swelling. In the chest there are bilateral basal crackles and wheezes. Her
joints show slight active inflammation and deformity, in keeping with the history of
rheumatoid arthritis.
NormalHaemoglobin 11.5 g/dL 11.7–15.7 g/dL
Mean corpuscular volume (MCV) 86 fL 80–99 fL
White cell count 13.2% 109 /L 3.5–11.0% 109 /L
Platelets 376 % 109 /L 150–440% 109 /L
Sodium 125 mmol/L 135–145 mmol/L
Potassium 4.7 mmol/L 3.5–5.0 mmol/L
Urea 8.4 mmol/L 2.5–6.7 mmol/L
Creatinine 131 &mol/L 70–120&mol/L
Glucose 4.8 mmol/L 4.0–6.0 mmol/LINVESTIGATIONS
Questions
- What is the diagnosis?
- How would you explain the abnormal investigations?
- How would you manage this case?