Acute confusional state and bronchogenic carcinoma with cerebral metastasis

Case history

A 75 year old man presented with a four week history of an acute confusional state, marked weight loss, and deteriorating mobility. After admission he suffered a grand mal seizure. He was known to have longstanding essential hypertension controlled with atenolol and chlorthalidone. He had smoked 15 cigarettes a day for almost 40 years. He had previously worked as an electrician and had occasionally been in contact with asbestos sheets.

On examination he was drowsy with a Glasgow coma scale of 8/15, haemodynamically stable with a blood pressure of 108/60 mm Hg, and a heart rate of 76 beats/min with an irregular rhythm. He was apyrexial and there were no obvious signs of sepsis. Chest examination revealed tracheal deviation to the left, decreased left sided chest expansion, normal breath sounds and no additional sounds. Neurological examination revealed left sided signs with decrease in power of 4/5, normal reflexes, and up going plantar.

Investigations on admission

Haemoglobin 14.0 (normal range 11.0-16.5) g/l, white cell count 9.79 (4-11) * 10⁹/l, platelets 418 (140-400) * 10⁹/l, …