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Coma Exam

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262. Psychogenic polydipsia

and/or developmental disability. There may be no physical effects, but hyponatraemia can occur. History and exam presence of risk factors water-seeking and drinking polyuria headache or nausea lethargy or confusion seizures, delirium, or coma mental illness anxious, middle-aged women developmental disability disorders smoking Diagnostic investigations plasma osmolality urine osmolality urine sodium serum sodium 24-hour urine volume urinalysis serum urea water restriction test vasopressin test plasma ADH CXR (...) headache, nausea, cramping, hyporeflexia, dysarthric speech, lethargy, confusion, seizures, and delirium. Coma and even sudden death can ensue as sodium status worsens. Complications of psychogenic polydipsia include incontinence and enuresis, bladder dilation and hydronephrosis, renal and congestive heart failure, and osteoporosis and associated pathological fractures. Diagnosis is one of exclusion. Other medical causes of polydipsia, polyuria, and/or hyponatraemia need to be ruled out. Management

2017 BMJ Best Practice

263. Foreign body aspiration

. Definition Foreign body aspiration is the inhalation of a foreign body into the larynx and respiratory tract. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001 Mar 1;344(9):665-71. http://www.ncbi.nlm.nih.gov/pubmed/11228282?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: Loquat seed completely occluding the bronchus intermedius From the collection of Dr Septimiu Murgu and Dr Henri Colt; used with permission [Citation ends]. History and exam (...) presence of risk factors choking crisis unilateral decreased breath sounds unilateral wheezing intractable cough fever dyspnoea bilateral wheezing decreased level of consciousness (Glasgow coma score <9) age <4 years age >70 years bulbar dysfunction male gender cerebrovascular disease dementia Diagnostic investigations CXR CT chest bronchoscopy Treatment algorithm ACUTE Contributors Authors Associate Professor of Medicine Section on Pulmonary, Critical Care, Allergy, and Immunologic Disease Wake Forest

2017 BMJ Best Practice

264. West Nile virus

. No vaccine or specific antiviral treatment is available. Definition An infection caused by West Nile virus (WNV), a flavivirus of the family Flaviviridae, that is transmitted to humans by mosquito bites or through contact with infected blood. The majority of cases are asymptomatic, but infection can cause a self-limited influenza-like illness (West Nile fever or WNF) or, rarely, West Nile neuroinvasive disease (WNND). Kunjin virus is a subtype of West Nile virus endemic to Oceania. History and exam fever (...) of sudden onset malaise myalgia arthralgia pharyngitis anorexia abdominal pain visual disturbances headache rash lymphadenopathy conjunctival injection multi-focal chorioretinal lesions chorioretinitis and inflammatory vitritis seizures respiratory distress jaundice epigastric tenderness mild confusion disorientation stupor/coma neck stiffness Kernig's sign Brudzinski's sign muscle paralysis parkinsonism ataxia myoclonus tremors nausea/vomiting generalised muscle weakness splenomegaly retinal

2017 BMJ Best Practice

265. Superior vena cava syndrome

, neck, and arms, often with cyanosis, plethora, and distended subcutaneous vessels. Wilson LD, Detterbeck FC, Yahalom J. Clinical practice: superior vena cava syndrome with malignant causes. N Engl J Med. 2007 May 3;356(18):1862-9. http://www.ncbi.nlm.nih.gov/pubmed/17476012?tool=bestpractice.com It can be caused by either intraluminal obstruction of the SVC or extrinsic compression. History and exam presence of risk factors localised oedema of the face and upper extremities dyspnoea facial plethora (...) cough distended neck veins distended chest veins hoarseness of voice lymphadenopathy blurred vision stridor confusion/stupor anorexia weight loss haemoptysis headache chest pain mental changes fever skin rash arthralgia laryngeal oedema cyanosis papilloedema coma smoking multiple pacemaker leads age >50 years radiation Diagnostic investigations chest x-ray chest CT chest MRI ultrasound of upper extremities venography biopsy sputum cytology thoracentesis sputum culture ESR C-reactive protein

2017 BMJ Best Practice

266. Thrombotic thrombocytopenic purpura

History and exam non-specific prodrome severe neurological symptoms (coma, focal abnormalities, seizures) mild neurological symptoms (headache, confusion) fever age 30 to 50 years digestive symptoms (nausea, vomiting, diarrhoea, abdominal pain) weakness bleeding symptoms (purpura, ecchymosis, menorrhagia) black ethnicity female gender obesity pregnancy (near term or post-partum period) cancer therapies HIV infection bone marrow transplantation antiplatelet agents quinine Diagnostic investigations (...) are usually non-specific, although half of patients have neurological abnormalities. Pentad of fever, renal failure, haemolytic anaemia, thrombocytopenia, and neurological changes are often seen, although most patients do not have the entire pentad. Examination of the peripheral smear is critical and shows evidence of microangiopathic haemolytic anaemia with fragmented RBCs (schistocytes) and thrombocytopenia. An urgent haematological consultation is recommended for suspected cases. Plasma-exchange

2017 BMJ Best Practice

267. Disseminated intravascular coagulation

can include epistaxis, gingival bleeding, haematuria, oliguria, cough, dyspnoea, fever, delirium, and coma. Physical examination may reveal petechiae, ecchymosis, gangrene, mental disorientation, hypoxia, hypotension, and GI bleeding. Diagnosis is based on presence of ≥1 known underlying conditions causing DIC plus abnormal global coagulation tests: decreased platelet count, increased prothrombin time, elevated fibrin-related maker (D-dimer/fibrin degradation products), and decreased fibrinogen (...) /16504043?tool=bestpractice.com History and exam presence of underlying disorders oliguria, hypotension, or tachycardia purpura fulminans, gangrene, or acral cyanosis delirium or coma petechiae, ecchymosis, oozing, or haematuria major trauma/burn/organ destruction or sepsis/severe infection severe obstetric disorders or complications solid tumours and haematological malignancies severe toxic or immunological reactions major vascular disorders (large aortic aneurysms or giant haemangiomas) Diagnostic

2017 BMJ Best Practice

268. Salicylate poisoning

. http://informahealthcare.com/doi/full/10.1080/15563650600907140 http://www.ncbi.nlm.nih.gov/pubmed/17364628?tool=bestpractice.com Chronic poisoning tends to occur as a result of repeated exposure to high-dose aspirin or equivalent (150 mg/kg/day). History and exam ingestion of 150 mg/kg or more, or 6.5 g or more, of aspirin or aspirin-equivalent oil of wintergreen ingestion unknown toxin ingestion or exposure self-harm or suicide attempt abnormal behaviour children aged 3 years or younger (...) and adults aged 70 years or older nausea, vomiting, haematemesis, epigastric pain fever and diaphoresis shortness of breath tachypnoea, hyperpnoea, Kussmaul's respirations tinnitus and/or deafness malaise and/or dizziness movement disorders, asterixis, stupor confusion and/or delirium (irritability, hallucinations) coma and/or papilloedema seizures rales plus low oxygen saturation volume depletion skin rash ingestion of 150 mg/kg or more, or 6.5 g or more, of aspirin or aspirin-equivalent ingestion

2017 BMJ Best Practice

269. Cavernous sinus thrombosis

, ears, teeth, or mouth), affecting the cavernous sinus and its structures. Aseptic CST is usually a thrombotic process that is a result of trauma, iatrogenic injuries, or prothrombotic conditions. History and exam presence of risk factors rapid onset of signs and symptoms (acute septic CST) headache fever peri-orbital oedema chemosis and proptosis lateral gaze palsy ophthalmoplegia profound sepsis (acute septic CST) ptosis and mydriasis papilloedema and/or retinal-vein dilatation decreased corneal (...) reflex hypo- or hyper-aesthesia in the distribution of the ophthalmic and maxillary nerves mental state changes (e.g., confusion, drowsiness, coma) clinically detectable primary infection site meningismus (nuchal rigidity, photophobia, and headache) positive Kernig's or Brudzinski's signs seizures loss of visual acuity recent hx of acute sinusitis hx of facial infections hx of peri-orbital infection hx of otitis media, mastoiditis, or petrositis hx of dental or oral infection hx of sepsis

2017 BMJ Best Practice

270. Hepatic encephalopathy

Hepatic encephalopathy Hepatic encephalopathy - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Hepatic encephalopathy Last reviewed: February 2019 Last updated: December 2017 Summary A neuropsychiatric syndrome caused by acute or chronic hepatic insufficiency. Symptoms vary in severity from a mild alteration in mental state to coma but are often reversible with treatment. Causation is thought to be multi-factorial (...) in cognition that cannot be better accounted for by a pre-existing or evolving dementia' that develops over a short period of time and fluctuates in severity. Minimal HE comprises those patients who have no recognisable clinical symptoms of brain dysfunction. Therefore, the prerequisite for the diagnosis of minimal HE is the careful exclusion of clinical symptoms. History and exam presence of risk factors mood disturbances sleep disturbances motor disturbances advanced neurological deficits palmar erythema

2017 BMJ Best Practice

271. Venezuelan equine encephalitis virus infection

infections may result in more serious neurological complications (e.g., seizures and coma), haemorrhage, or death. Overall mortality during outbreaks of VEEV have rarely exceeded 1%. Weaver SC, Paessler S. Alphaviral encephalitides. In: Barrett ADT, Stanberry LR, eds. Vaccines for biodefense and emerging and neglected diseases. San Diego, CA: Elsevier; 2009:340-354. Mortality occurs mainly in children, and is generally attributable to consequences of neurological involvement. Quiroz E, Aguilar PV (...) , Cisneros J, et al. Venezuelan equine encephalitis in Panama: fatal endemic disease and genetic diversity of etiologic viral strains. PLoS Negl Trop Dis. 2009;3:e472. http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0000472 http://www.ncbi.nlm.nih.gov/pubmed/19564908?tool=bestpractice.com History and exam presence of risk factors acute onset of fever headache myalgia arthralgia retro-orbital pain tachypnoea tachycardia chills altered mental status nausea/vomiting seizures GI bleeding

2017 BMJ Best Practice

272. Hypercalcaemia of malignancy

Jan 27;352(4):373-9. http://www.ncbi.nlm.nih.gov/pubmed/15673803?tool=bestpractice.com Horwitz MJ, Hodak SP, Steward AF. Non-parathyroid hypercalcemia. In: Rosen CJ, ed. Primer on the metabolic bone diseases and disorders of mineral metabolism. 8th ed. Washington, DC: American Society of Bone and Mineral Research; 2013:562-71. History and exam presence of risk factors history of malignancy normal physical exam poor skin turgor and/or dry mucous membranes confusion fatigue constipation loss (...) of appetite nausea polyuria polydipsia bone pain use of hypercalcaemia-inducing medication stupor coma non-metastatic malignancy metastatic skeletal involvement lymphoma Diagnostic investigations total serum calcium serum ionised calcium serum albumin comprehensive metabolic panel resting ECG serum intact parathyroid hormone serum parathyroid hormone-related peptide serum phosphorus serum calcitriol (1,25-dihydroxyvitamin D) serum 25-hydroxyvitamin D skeletal survey chest x-ray Treatment algorithm ACUTE

2017 BMJ Best Practice

273. Jaundice in the newborn

bilirubin encephalopathy is a clinical syndrome which occurs when there is severe hyperbilirubinaemia. Features include lethargy, irritability, poor suck, abnormal muscle tone and posture (opisthotonus), high-pitched cry, apnoea, and eventually seizures and coma. Chronic bilirubin encephalopathy describes the clinical features resulting from acute encephalopathy. These include athetoid cerebral palsy, seizures, developmental delay, learning difficulties, vision and hearing problems, and dental dysplasia (...) . The prognosis for babies with jaundice due to an underlying condition depends on the cause. Physiological jaundice is generally harmless and resolves by 2 weeks of age. To diagnose neonatal jaundice, the baby should be examined in bright, preferably natural light. If there is doubt about the diagnosis, referral to a neonatologist or paediatrician (depending on local availability) for further assessment should be considered. An assessment should be undertaken to determine the extent of jaundice and identify

2018 NICE Clinical Knowledge Summaries

274. Jaundice in adults: How should I assess a person with jaundice?

. Drugs — prescribed and over-the-counter, including herbal medications and dietary supplements. Always ask about potential paracetamol overdose. Occupation — exposure to viral hepatitis, HIV, or hepatotoxic chemicals. Family history of inherited anaemias or haemoglobinopathies. Possibility of pregnancy — jaundice associated with pregnancy is an obstetric emergency. See the CKS topic on for further information. How should I examine a person with jaundice? Carry out an examination looking for: Signs (...) mellitus. See the CKS topic on for further information. Gynaecomastia (breast enlargement in men), with loss of body hair and testicular atrophy — due to reduced oestrogen breakdown. Signs of liver failure: Altered neuromuscular function such as ataxia, nystagmus, or asterixis (coarse flapping tremor) can occur with hepatic encephalopathy. Altered mental state such as drowsiness, confusion, disorientation, or coma. Bruising, petechiae, or purpura. Lymphadenopathy: Enlargement of the left

2018 NICE Clinical Knowledge Summaries

275. Screening of fetal aneuploidies whereby non-invasive prenatal test (NIPT)

. The comparator, chosen by application of EUnetHTA criteria [1], is first-trimester serum screening (pregnancy-associated plasma protein A (PAPP-A) and ß subunit of human chorionic gonadotropin (ß-hCG)) and/or an ultrasound scan to measure fetal nuchal translucency (NT) or fetal crown-rump length (CRL) and maternal age. Fetal karyotyping or birth outcomes determined through clinical examination or follow-up of the newborn are considered the reference standards. The effectiveness of the screening processes (...) ). The EC declaration can be done by a declaration of conformity of full quality assurance (Annex IV) or by EC-type examination (Annex V) couplet with EC verification or EC declaration of conformity (production quality assurance) (Annex VI). For all other trisomy determinations, companies are required to comply only with the general requirements for in vitro medical devices (Annex III). Information regarding CE marking is lacking for many of the existing providers or laboratories. Table 4 summarises

2018 EUnetHTA

277. Continuous glucose monitoring (CGM real-time) and flash glucose monitoring (FGM) as personal, standalone systems in patients with diabetes mellitus treated with insulin

and consistent management approach. They should cover these basic principles of diabetes management [16]: • Interventions to promote and support healthy lifestyles, including healthy diet, physical activity, avoidance of tobacco use, and harmful use of alcohol. • Medication for blood glucose control – insulin or oral hypo-glycaemic agents as required. • Medication to control cardiovascular disease risk. • Regular exams for early detection of complications: comprehensive eye examination, measurement of urine (...) , ongoing, and organized care delivered by a team of skilled healthcare providers. The majority of care can be provided at the primary care level with basic interventions involving medication, health education and counselling, and consistent follow-up. A periodic referral for spe- cialist care is required in order to perform more complicated interventions (for example, compre- hensive eye examinations, laser and surgical treatment of eye complications, complex kidney function tests, and tests

2018 EUnetHTA

278. Poisoning or overdose: Symptoms and signs of drugs that are commonly involved in poisoning or overdose

that are commonly involved in poisoning or overdose The diagnosis of poisoning cannot be made on a single sign. The symptoms and signs which may be present following poisoning with certain drugs are listed in Table 1. In cases where it is unclear which poison(s) have been taken, the history and examination can sometimes be helpful in suggesting what class of substance might be involved. Table 2 includes a number of toxidromes, the syndrome of signs and symptoms caused by certain classes of substances, usually (...) to encephalopathy, hypoglycaemia, haemorrhage, cerebral oedema and death. People may also present with coma or a reduced level of consciousness if they have taken paracetamol with a drug that reduces the level of consciousness, such as opioids (for example a combined paracetamol/opioid preparation) or alcohol. Aspirin Hyperventilation, tinnitus, deafness, vasodilatation, and sweating. Coma if very severe poisoning. Tricyclic and related antidepressants Dry mouth, seizures, coma, cardiac conduction defects

2018 NICE Clinical Knowledge Summaries

279. Poisoning or overdose: Scenario: Management of poisoning or overdose

resuscitation (CPR) immediately, and call for an ambulance. Assessment of a person who is acutely poisoned involves assessing their level of consciousness, breathing and circulation; taking a history and performing an examination. Assess the person's consciousness. The Glasgow coma scale is the method most commonly used. Measure respiratory rate. If a pulse oximeter is available, measure oxygen saturations. Note this may not be accurate if there is poor peripheral perfusion, or carboxyhaemoglobin (...) in inconsistency between an unreliable history and laboratory blood and urine tests. When was it taken? Try and establish the exact timing(s) of ingestion or contact. This is especially important in paracetamol poisoning. Was it a single acute overdose, staggered or chronic? What was the route of administration? By mouth, inhalation, or injection? Ask about any symptoms the person may be experiencing, depending upon the substance(s) involved. See . Perform an examination, depending on the clinical situation

2018 NICE Clinical Knowledge Summaries

280. Management of acute (fulminant) liver failure

), and may need renal replacement therapy (RRT) to treat the acidosis. In these cases, othercompoundingaetiologiesshouldalsobesoughtsuchassal- icylate, tricyclic or methanol ingestion. The clinical evolution of POD is often that of rapidly progres- sive multi-organ failure (MOF) and HE, which may progress from a mild grade 1 to grade 4 coma over a period of hours. Patients who do not meetcriteria for emergency LTx have a good progno- sis, and those whomeetthe criteriamaystill have a survival rate of20–40 (...) for underlying malig- nancies are necessary [34,95]. Wilson disease. The classic presentation of acute Wilson dis- ease includes HE in young patients ( 30, head in neutral position and intubate, ventilate and sedate if progresses to >3 coma. Low threshold for empirical start of antibiotics if hemodynamic deterioration and/or increasing encephalopathy with in?ammatory phenotype In case of evolving HE intubation and sedation prior to the transfer Ensure volume replete and normalize biochemical variables (Na

2017 European Association for the Study of the Liver

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