Introduction
The patient is a 24 year old male. He was found on the floor by his friend who came to pick him up for work. On physical assessment, the young man was lying on the floor with his tight arms curled towards his chest. His head was arched back as well as his eyes rolled back with a fixed gaze. He had his mouth open and his facial muscles appeared to be pulled back tightly. Nothing else is known about this patient. This discussion will involve the physical assessment of the patient in order to come up with a differential diagnosis.
Clinical Manifestation
From this assessment, it is noticeably clear that there are two outstanding signs. The stiffness of muscles and unconsciousness are the key clinical symptoms that come into play in this case scenario. With these signs in mind, we can draw a working hypothesis which will serve as the starting point for our diagnosis. This will involve coming up with differential diagnosis based on the abovementioned symptoms.
Differential Diagnosis
Seizures
The brain functions by discharging electrons which are relayed to different body parts through by the motors. Biochemical processes in the cells serve to excite the neurons which in charge generate electrical impulses causing the excitement. A person who is at a risk of getting seizures normally has his brain function altered, and this makes him/her vulnerable to overexcitement. An abnormal number of electrons in the brain, discharged in excess and suddenly, will cause an abrupt change to the motor sequence. This will result in a moment of unconsciousness and muscle rigidity. Seizures may be due to different causes and seizure activity; history and frequency of the case serve to distinguish the causes. Recurrent seizures are normally associated with epilepsy, a condition that indicates that the motor function has been altered, completely facilitating recurrence of seizures
There are different types of seizures, generalised and focal or localized ones. Generalised seizures occur when both hemispheres of the brain discharge abnormal electrical pulses concurrently. The result is temporary loss of consciousness or a combination of motor function impairment and unconsciousness. The second form of seizure is a localized seizure also known as focal seizure. This affects a particular part of the brain, and the outcome or manifestation will normally show the affected brain functional area. These seizures may spread to the neighbouring cortical areas or to the whole cortex. In case this happens, a secondary Generalised seizure ensues.
Rationale
Disabilities that are linked to development are major causes of seizures. Seizures can also be caused by head injury, brain tumours, head trauma and other diseases. While onetime seizures can occur to anyone, recurrent unprovoked seizures may be a sign of epilepsy. The outcome of a seizure may be physical injuries or some other life threatening impacts. Therefore, it is important to minimize such effects by proper care and management.
The only person who can order treatment is the medical consultant in the case management team. He does this after medically diagnosing and classifying the seizure. The clinical consultant may not be able to accurately diagnose seizures due to lacking communication, complex clinical manifestation and insufficient history. He must rely on details given by observers to make his diagnosis. Accurate description and recording of seizure activity and proper reporting of the same are of great importance in aiding disease management and treatment (Nursing Management of Seizures 2006, p. 1). All team members dealing with patients who are at risk of getting seizures should be educated on observing and recording seizure activity. They should also be equipped with the skills necessary for management and protection of the victim both during and after the seizure. These will enable the medical consultant in charge to make a diagnosis. Seizures may occur in his absence, hence causing the need for clear recording.
It is important to take note of consequential long-term impact on the patient. Social stigmatization, cognitive defects and developmental disorders are some of the major impacts (Moran, Poole, Bell et al 2004)
Diagnosis and management
Seizures can be onetime or recurrent. In case of a onetime seizure, it is always good to dig into the root cause of the case and treat it. It could be due to an onset of epilepsy or other problem or even due to head injury. On the other hand, recurrent seizures are epileptic and may be managed by routine medication. Based on the characteristics, the medical expert can deduce the cause and offer appropriate guidelines and treatment. Electroencephalography can be used to confirm a suspected cause of seizure. A CT scan can also be carried out to rule out any possibility of head injury or brain tumours before epileptic management is initiated. Levels of anticonvulsants are also checked as a green light to move forward with treatment. In our case, we are not given any history of the young man with seizures; this means that it will be treated as a onetime seizure, therefore calling for a need to try to investigate the cause. When epileptic seizures are confirmed, treatment with anticonvulsants should be initiated, and routine care like medical reviews should also be scheduled. It is hard to treat seizures completely, especially if they are a result of birth defects in the brain, unless by corrective surgery.
Meningoencephalitis
This is an infection of the central nervous system which clinical manifestation resembles both those of meningitis, which is an inflammation of the meninges, and encephalitis, an inflammation of the brain. Some major causes are bacteria, fungi, and other disease causing micro-organisms. The larger percentage of all cases is caused by viruses. Herpes simplex viruses cause about 10% of all the occurrences. This may be caused as well by Herpes Simplex type 1(HSV1), the same virus that is responsible for cold sores. It can also be caused by type 2 Herpes Simplex virus (HSV2) which is sexually transmitted and can also be transmitted from mother to child at birth. HSV1 can also be transmitted sexually to the genital area. The bacteria that cause meningoencephalitis are free living and include Naegleria fowleri which causes primary meningoencephalitis. This condition cannot be clinically differentiated from acute bacterial meningitis. Another bacterial species are Balamuthia mandrillari, Acanthamoeba and Sappinia. All these cause granulomatous amoebic encephalitis. This condition is more chronic, and its clinical manifestation can resemble that of a brain abscess, chronic meningitis or Central Nervous System malignancy.
Rationale
Meningoencephalitis is clinically manifested as a combination of meningitis and encephalitis. The symptoms of meningitis include headache, fever, light sensitivity and a stiff neck while those of encephalitis are sleepiness, confusion, seizure and any focal neurological deficit or partial seizure. If any of the symptoms of encephalitis ( Kennedy 2012), particularly those that relate to neural function impairment, manifests together with symptoms of meningitis, then this can be diagnosed as meningoencephalitis. Speaking of symptoms, there are those that can be described as the clinical signs of meningoencephalitis. They include personality changes, unconsciousness, unusual behavior, headache, fever, sensitivity to light, confusion and neck stiffness. In our case, the young man was unconscious with his head arched backwards indicating stiffness of neck. Other signs may not be clear as they were not visible, but we cannot rule out the possibility of meningoencephalitis as well (Johns Hopkins Medicine, n.d)
Diagnosis and management
The confirmatory tests for suspected meningoencephalitis include lumbar puncture also known as spinal tap. This procedure is used to collect a spinal fluid sample that is to be analysed in the lab. The cells and other components present will help in the diagnosis. A CT scan can also be carried out to help the doctor analyse the brain and observe any abnormalities in the brain. An EEG test to measure the brain waves can also be done. For a baby suspected to have been infected with the virus during birth, his/her blood and spinal fluid samples can be used to clear the doubts.
Treatment is to be made by intravenous acyclovir which is an antiviral drug. The dosage is injected into the body normally between 10 to 14 days. Anti-inflammatory drugs to reduce the swelling in the brain and a treatment or prevention drug course against seizures can also be prescribed. For babies, the treatment normally goes for several weeks. It can be prevented by avoiding ways through which the Herpes virus which is the major cause and other disease causing organisms are transmitted. Transmission of Herpes virus can be prevented by sexual abstinence or faithfulness to one partner whose test status you know. Using latex condoms during sexual intercourse can reduce but not eliminate the risk of infection.
Bearing in mind that most individuals are infected with the virus before they are twenty years, it is wise to stay away from kissing people with cold sores. Cold sores are evidence of the person in question being a carrier of the virus. Once infected, the virus becomes dormant although it is still present in the body and only re-emerges during the outbreaks. To protect the new born from chances of getting infected during birth, it is good to opt for a caesarean section if, during pregnancy, the mother has an outbreak of genital herpes.
The severity of the disease often dictates the impact on the body and brain of the patient. In severe cases, the result may be a long-term damage which may cause the victim to have functional impairment of the sensory organs. Hearing, seeing, speaking, thinking and movement may fully or partially be disabled by severe meningoencephalitis.
Head injury
This refers to trauma that causes harm to brain, scalp or skull. Head injury can refer to a minor trauma or a major injury on the brain. There are two categories, open or closed head injury. For the closed one, the skull is not broken. It refers to a situation where the head has been hit on hard by an object, but the object did not penetrate the skull. On the other hand, an open head injury refers to a blow in which the striking object broke the skull and entered into the brain. The blow may be from a bullet when one is shot in the head or when a person is hit, while moving at a high speed. The most common type of brain injury is called concussion which is the shaking of the brain. Scalp wounds, and skull fractures penetrate into the brain causing other forms of head injuries. These injuries may result in internalized bleeding in the brain tissue known as subarachnoid hemorrhage and bleeding in the areas that surround the brain known as subdural hematoma. Head injuries are caused by traumatic incidents, such as falls, physical assault, for instance, when one is attacked by robbers, suffers from road or other traffic accidents or other forms of accidents.
Rationale
Head injuries can be characterized by symptoms that manifest right away or develop slowly over the time. These may include drowsiness, severe headache, stiff neck, abnormal behavior, and loss of consciousness; however, it might be multiple bouts of vomiting (Tolan 2009)
Head injury may not be always visible; the damage could be internalized, such as when the brain bruises against the skull. It is, therefore, not advisable to rule out head injury in the event that clinical signs of the condition are present, but there are no signs of physical injury (Biros & Heegaard 2009)
Management
In the event of a moderate or severe head injury, call the emergency rescue via 911 and give first aid while you are waiting their arrival. It is important to take extra caution to avoid further damages to the casualty; and one thing to remember is that head and spinal injuries are closely related. Therefore, it is good to always assume a spinal injury in the event of head injury. Check the patient’s breathing and circulation and take the corrective action like rescue breathing, if necessary. Check the heart rate and breathing, and if they are normal and the patient is unconscious, stabilize the head and neck to prevent the movement (National Institutes of Health 2012). Use a clean cloth to stop bleeding by holding it firmly against the wound, and if soaked in blood, do not remove it, hold another cloth on top of that. Nothing should be removed from the wound, neither debris nor foreign objects. In case the victim of the seizures is vomiting, roll him/her over holding his/her head, neck and body so that they remain stable and let him/her lie on the side to avoid chocking. Apply ice packs on swollen areas (National Institute of Health, n.d). If the injury is mild, no treatment is required, but the victim should be closely watched for any symptoms of severe injury that may develop later (Atabaki 2007). In case of severe injury symptoms, contact a medical personnel.
Treatment begins with cardiopulmonary stabilization followed by assessment of the neurological status. During cardiopulmonary stabilization, an initial resuscitation is very important as it helps prevent hypotension and hypoxia. Patients with any of these complications stand a higher chance of dying than those without it. A neurological examination on a patient, who received muscle relaxants, is performed on the papillary response. A CT scan of the head is performed which gives the way forward. For instance, if there is an initial surgical lesion, the patient is transferred to the operating theatre for an emergency operation. Any hematoma that is present, as shown by the scan results, should be removed immediately. After surgery, in the event that an initial surgical lesion has been present, or if there has been none performed, meaning there has been no surgery done, the first phase of treatment is initiated. This starts with resuscitation of fluids, and once the fluid level is assumed to be normal, administration of fluids starts intravenously to maintain the patient in a euvolemi or hypervolemia state. Also, head elevation is of much help to increase the venous outflow from the brain. However, hypovolemic patients and those suspected to have spinal injury or an unstable spine should not be elevated. Short lived sedation should be administered.
They should be short lived because routine neurological assessments need to be carried out. Fast acting analgesics are also required to relieve the patient of the pain. Normally, traumatic patients are in great pain. Use of anticonvulsants is debatable as no evidence has been put across to show that use of anticonvulsants decreases the likelihood of onset of seizures later on, after a head injury. Dilantin administered in the first week of injury decreases the chances of getting seizure attacks within seven days of injury but does not completely rule out its probability. It is, therefore, not advisable to use anticonvulsants for more than seven days. Then ICP monitors are put in place to help keep these levels under control. Treatment of patients with high levels of ICP is very complicated as there is no definitive or standard treatment course. Each patient is treated as per his/her condition. The intracranial volume is composed of the total brain volume, intracranial mass lesions, intravascular blood volumes and the CSF. These dictate the level of ICP, and in case it is elevated, one of these constituents must be decreased to enhance intracranial compliance and reduce ICP. By elevating the head, blood outflow is increased and consequently reducing ICP. Hypocapnia reduces blood flow through the cerebral arteries. This is neither a curative measure nor the improvement of the survival chances. It is a stand in the gap procedure that is used as proper curative while the corrective measure is awaited. The brain tissue volume can be increased by swelling or inflammation. This means that measures that can prevent edema will significantly reduce ICP considering that the brain occupies the largest part of the intracranial volume. CSF (Cerebrospinal Fluid) volume can be reduced by regular hourly draining produced continuously.
Conclusion
From the above analysis, it is clear that one of the three differential diagnoses discussed above could be the cause of the young man in question’s suffering. However, the symptomatic assessment cannot be conclusive hence treatment cannot begin. To come to a conclusion, the patient should be ferried to a healthcare facility. To be sure that our patient is safe and has a better chance of surviving, we need to ensure all the vital signs are taken care of before going to hospital. The breathing as well as heartbeat and blood pressure should be checked. Any first aid measures that may be required to correct any abnormalities should be administered.
As a conclusive point, differential diagnoses should not form a basis for any treatment to be initiated. It should be used more as a working hypothesis to narrow down the list of possibilities that can be manifested with the same signs. It also forms a basis to build the query into the possible causes and hence the pathological analysis or any other tests that should be carried out.
References
Atabaki, SM 2007, ‘Pediatric head injury’, Pediatrics in Review, vol. 28, no. 6, pp. 215-224, Web.
Biros, M & Heegaard, W 2009, ‘Head injury’, in JA Marx et al. (eds), Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Mosby, St. Louis, Mo., pp. 295-323.
‘Head Injury minor‘, NHS Choices, Web.
‘Herpes Meningoencephalitis’ n.d, Johns Hopkins Medicine, Web.
Kennedy, PGE 2012. ‘Viral encephalitis: Causes, Differential Diagnosis and Management’, Journal of neurology, neurosurgery and psychiatry. vol. 75, no. suppl 1, pp. i10-i15, Web.
Moran, NF et al 2004, ‘Epilepsy in the United Kingdom: seizure frequency and severity, anti-epileptic drug utilization and impact on life in 1652 people with epilepsy‘, Seizure, vol. 13, no. 6, pp. 425-433.
National Institutes of Health 2012, Head injury – first aid, Web.
NICE 2010. ‘Transient loss of consciousness in adults and young people‘, NICE Clinical Guidelines, CG109, Web.
‘Nursing Management of Seizures’ 2006, SCDDSN Revision, Web.
Tolan, RW 2009, ’Amebic Meningoencephalitis’, Medscape references, Web.