Altered Mental Status Answers 293(d)A urinalysis is not required to make the diagnosis of eclampsia since
proteinuria may or may not occur. A urinalysis can be used to rule out a
urinary tract infection. An (e)ECG should be obtained to complete the
patient’s evaluation but can wait until after the head CT.
271.The answer is e.(Tintinalli, p 1346.)This patient presents with four
of the five symptoms classically associated with TTP.These include
thrombocytopenia, hemolytic anemia, neurologic deficits, renal impair-
ment, and fever.TTP develops with fibrin-strand deposition in small ves-
sels that attract platelets leading to platelet thrombi and thrombocytopenia.
Passing RBCs get sheared in occluded vessels resulting in microangiopathic
hemolytic anemia. Renal and neurologic impairment occur as a result of the
lodging of thrombi in respective circulations. Plasmapheresis decreases TTP
mortality from 90% to 10%. Adjunct therapies include fresh frozen plasma
infusion and steroids. It is important to realize that although patients may be
severely thrombocytopenic, platelet infusion is contraindicated since it
exacerbates the underlying cycle of thrombogenesis. Risk factors for TTP
include pregnancy, autoimmune disorders, drugs, infection, and malignancy.
Hemolytic-uremic syndrome (HUS) is a closely related entity usually seen in
children. There is pronounced renal dysfunction without altered mentation.
Henoch-Schönlein purpura (HSP) (a)is a small-vessel vasculitis mostly
seen in children and associated with a preceding upper respiratory illness in
about 50% of patients. It is characterized by purpura, usually lower extremities,
abdominal pain, and hematuria. Disseminated intravascular coagulation (DIC)
(b)is a coagulopathic state triggered by major trauma, infection, malig-
nancy, drugs, or pregnancy complications. The underlying process activates
the coagulation cascade which leads to diffuse thrombosis and coagulopathy
as platelets and coagulation factors are consumed. Patients with DIC have
profuse GI or puncture site bleeding, markedly prolonged PT/PTT times,
thrombocytopenia, and elevated fibrin split products. DIC management
involves treatment of the underlying disorder and replacement of depleted
coagulation cascade components. Von Willebrand disease (c)is the most
common bleeding disorder and involves deficiency or defect in von Wille-
brand factor, which normally aids in platelet adherence and carries factor VIII
in plasma. Von Willebrand disease presents clinically with GI bleeding, epis-
taxis, easy bruising, and prolonged bleeding. Idiopathic thrombocytopenic
purpura (ITP) (d)is a disorder of antibody-mediated platelet destruction. It is
acute in children, usually following a viral infection, and is chronic in adults
who often require splenectomy for definitive treatment.