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Coma Exam

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21. Acute aspiration

:818-826. http://www.ncbi.nlm.nih.gov/pubmed/21263315?tool=bestpractice.com This topic does not discuss the inhalation of foreign bodies. History and exam presence of risk factors intractable cough fever dyspnoea wheezing crackles decreased level of consciousness (Glasgow coma scale score <9) increased severity of illness general anaesthesia age >70 years male sex head trauma cerebrovascular disease endotracheal or tracheostomy tube dysphagia airway difficulties barium meal gastro-oesophageal

2018 BMJ Best Practice

22. Haemorrhagic stroke

spontaneous intracerebral haemorrhage is defined as haemorrhage in the absence of vascular malformations or associated diseases. Secondary intracerebral haemorrhage is from an identifiable vascular malformation or as a complication of other medical or neurological diseases that either impair coagulation or promote vascular rupture. History and exam neck stiffness history of atrial fibrillation history of liver disease visual changes photophobia sudden onset altered sensation headache weakness sensory loss (...) aphasia dysarthria ataxia history of haematological disorder vertigo nausea/vomiting altered level of consciousness/coma confusion gaze paresis hypertension advanced age male sex Asian, black and/or Hispanic family history of haemorrhagic stroke haemophilia cerebral amyloid angiopathy autosomal dominant mutations in the COL4A1 gene hereditary haemorrhagic telangiectasia autosomal dominant mutations in the KRIT1 gene autosomal dominant mutations in the CCM2 gene autosomal dominant mutations

2018 BMJ Best Practice

23. Hyperosmolar hyperglycaemic state

, weakness, weight loss, tachycardia, dry mucous membranes, poor skin turgor, hypotension, and, in severe cases, shock. Altered sensorium (lethargy, disorientation, stupor) is common and correlates best with effective serum osmolality. Coma is rare and, if seen, is usually associated with a serum osmolality >340 mmol/kg (>340 mOsm/kg) Treatment includes correction of fluid deficit and electrolyte abnormalities, and intravenous insulin. Definition Hyperosmolar hyperglycaemic state (HHS), also known as non (...) ?tool=bestpractice.com History and exam altered mental status polyuria polydipsia weight loss weakness dry mucous membranes poor skin turgor tachycardia hypotension seizures hypothermia shock abdominal pain focal neurological signs infection inadequate insulin or oral antidiabetic therapy acute illness in a known patient with diabetes nursing home residents postoperative state precipitating medications total parenteral nutrition (TPN) Cushing's syndrome hyperthyroidism acromegaly Diagnostic

2018 BMJ Best Practice

24. Paracetamol overdose

gastrointestinal symptoms at initial presentation. Untreated paracetamol poisoning may cause varying degrees of liver injury over the 2 to 4 days following ingestion, including fulminant hepatic failure. Rarely, massive overdose may initially present with coma and severe metabolic acidosis. Presentation with coma may also occur if a combination preparation of paracetamol and opioid is taken in overdose, or after an overdose of multiple drugs. Hepatotoxicity is extremely rare in patients treated (...) . The definition of hepatotoxicity after paracetamol overdose is a serum AST concentration at least 1000 IU/L. Paracetamol is known as acetaminophen in some countries. History and exam attempted self-harm repeated non-prescription analgesic use for pain relief asymptomatic presentation nausea, vomiting, or abdominal pain right upper quadrant pain and tenderness jaundice confusion, decreased consciousness level, and/or asterixis history of self-harm history of frequent or repeated use of medications for pain

2018 BMJ Best Practice

25. Cholera

enterotoxin leads to continued activity of adenylate cyclase in intestinal epithelial cells and secretion of water and accompanying salts into the gut lumen. History and exam copious watery diarrhoea evidence of volume depletion age <5 years ingestion of shellfish FHx of recent, severe, cholera-like illness vomiting fever abdominal pain lethargy or coma ingestion of contaminated water ingestion of contaminated food inadequate sanitation recent heavy rains and flooding decreased gastric acid secretion

2018 BMJ Best Practice

26. Carbon monoxide poisoning

: early awareness and intervention can save lives. Postgrad Med. 1999;105:39-40,43-48,50. http://www.ncbi.nlm.nih.gov/pubmed/9924492?tool=bestpractice.com History and exam presence of risk factors nausea headache vomiting blurred vision dizziness cutaneous blistering tachycardia hypotension cardiac arrhythmias pulmonary oedema confusion coma seizures focal neurological abnormalities (e.g., hemiplegia) exposure to incomplete combustion of carbon-containing material exposure to methylene chloride (...) sources. Early symptoms are non-specific and include headache, dizziness, and nausea. Increasing exposure results in cardiovascular effects such as myocardial ischaemia, infarction, dysrhythmias, and cardiac arrest. Neurological symptoms include acute stroke-like symptoms, altered mental status, confusion, coma, and syncope. Diagnosis is based on the history, carboxyhaemoglobin levels and the patient’s symptoms. High-flow oxygen therapy, hyperbaric oxygen, and supportive therapy are the key treatments

2018 BMJ Best Practice

27. Subdural haematoma

neurological compromise. Control of raised intracranial pressure using head-of-bed elevation, analgesics, intubation with anaesthetics and sedation, hyperosmolar treatment, external ventricular drainage, barbiturates, or decompression hemicraniectomy may be required. Treatment complications include early or delayed re-accumulation of subdural haematoma, seizures, vascular injury to cortical veins and arteries or dural sinuses adjacent to the haematoma, strokes, persistent neurological deficit, coma (...) , and death. Definition A subdural haematoma is a collection of blood between the dural and arachnoid coverings of the brain. As the volume of the haematoma increases, brain parenchyma is compressed and displaced, and the intracranial pressure may rise and cause herniation. While the presence of subdural haematoma can be inferred by neurological decline and mechanism of traumatic injury, the diagnosis is typically made radiographically (computed tomography or magnetic resonance imaging). History and exam

2018 BMJ Best Practice

28. Wernicke's encephalopathy

are varied but typically include alterations of consciousness, eye movement abnormalities, and gait and balance disorders. Unless treated as an emergency with thiamine replacement parenterally, permanent neurological injury may occur. Definition Wernicke's encephalopathy is a neurological emergency resulting from thiamine deficiency with varied neurocognitive manifestations, typically involving mental status changes and gait and oculomotor dysfunction. History and exam mental slowing, impaired (...) concentration, and apathy frank confusion hx of GI surgery ocular motor findings mental status changes, ophthalmoplegia, and gait dysfunction alcohol dependence pre-existing conditions that predispose to malnutrition: for example, AIDS, cancer, prolonged vomiting, or diarrhoea mild irritability delirium acute psychosis coma miosis, anisocoria, light-near dissociation papilloedema, retinal haemorrhages tachycardia or hypotension hypothermia or hyperthermia hearing loss, seizures, and spastic paraparesis

2018 BMJ Best Practice

29. Benzodiazepine overdose

in coma and uncommonly death. Hojer J, Baehrendtz S. The effect of flumazenil (Ro 15-1788) in the management of self-induced benzodiazepine poisoning. A double-blind controlled study. Acta Med Scand. 1988;224(4):357-65. http://www.ncbi.nlm.nih.gov/pubmed/3142220?tool=bestpractice.com Diagnosis is suggested by the history and by exclusion of other aetiologies. Chronic overuse increases the risk of many other pathologies. History and exam presence of risk factors impaired mental status drowsiness (...) and in older people, and occasionally by medication error. Older people, who commonly have diminished drug clearance and polypharmacy, are at especially high risk of overdose. The key feature is excessive sedation with unremarkable vital signs and anterograde amnesia. Larger doses can cause coma and respiratory depression. Treatment of overdose is by symptom management, not by quantitative assay. Acute management consists of maintaining airway, respiration, and haemodynamic support while excluding other

2018 BMJ Best Practice

30. Paracetamol overdose

gastrointestinal symptoms at initial presentation. Untreated paracetamol poisoning may cause varying degrees of liver injury over the 2 to 4 days following ingestion, including fulminant hepatic failure. Rarely, massive overdose may initially present with coma and severe metabolic acidosis. Presentation with coma may also occur if a combination preparation of paracetamol and opioid is taken in overdose, or after an overdose of multiple drugs. Hepatotoxicity is extremely rare in patients treated (...) . The definition of hepatotoxicity after paracetamol overdose is a serum AST concentration at least 1000 IU/L. Paracetamol is known as acetaminophen in some countries. History and exam attempted self-harm repeated non-prescription analgesic use for pain relief asymptomatic presentation nausea, vomiting, or abdominal pain right upper quadrant pain and tenderness jaundice confusion, decreased consciousness level, and/or asterixis history of self-harm history of frequent or repeated use of medications for pain

2018 BMJ Best Practice

31. Assessment of delirium

encephalopathy Renal failure Hypernatraemia Hyponatraemia Hypercalcaemia Meningitis/encephalitis Brain tumour Post-ictal state Dehydration (volume depletion) Constipation Traumatic head injury Adrenal crisis Thyrotoxicosis Myxoedema coma Brain abscess Neurosyphilis Wernicke's encephalopathy Contributors Authors Associate Professor Yale University School of Medicine New Haven CT Disclosures MP is on the writing committee for the American Board of Internal Medicine Critical Care exams. MP has lectured (...) the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition, substance intoxication, or substance withdrawal. The changes in attention and cognition must not occur in the context of a severely reduced level of arousal, such as coma. Three clinical subtypes of delirium have been identified. Potter J, George J. The prevention, diagnosis and management of delirium in older people: concise guidelines. Clin Med

2018 BMJ Best Practice

32. Type 1 diabetes

there may be no evidence of autoimmune destruction of pancreatic beta cells; this is called idiopathic type 1 diabetes. History and exam presence of risk factors polyuria polydipsia young age weight loss blurred vision nausea and vomiting abdominal pain tachypnoea lethargy coma genetic predisposition geographic region infectious agents dietary factors Diagnostic investigations random plasma glucose fasting plasma glucose 2-hour plasma glucose plasma or urine ketones A1C (glycosylated haemoglobin

2018 BMJ Best Practice

33. Syndrome of inappropriate antidiuretic hormone

excessive arginine vasopressin (AVP) release. Severe neurological symptoms, such as altered mental status, seizure, and coma, may result from SIADH and these are always treated with hypertonic saline, with close monitoring to avoid overcorrection of serum sodium. Central pontine myelinolysis (osmotic demyelination syndrome) may occur with rapid correction of serum sodium in excess of 12 mmol/L/day (12 mEq/L/day). Vasopressin receptor antagonists (vaptans) are a new class of medicines that compete (...) insufficiency, and appropriate release of AVP secondary to extracellular volume depletion (hypovolaemia, due to gastrointestinal or renal loss) or intravascular volume depletion (hypervolaemia due to congestive heart failure, cirrhosis of the liver, or nephrotic syndrome) must be ruled out in order to diagnose SIADH. History and exam presence of risk factors absence of hypovolaemia absence of hypervolaemia absence of signs of adrenal insufficiency or hypothyroidism nausea vomiting altered mental status

2018 BMJ Best Practice

34. Haemorrhagic stroke

spontaneous intracerebral haemorrhage is defined as haemorrhage in the absence of vascular malformations or associated diseases. Secondary intracerebral haemorrhage is from an identifiable vascular malformation or as a complication of other medical or neurological diseases that either impair coagulation or promote vascular rupture. History and exam neck stiffness history of atrial fibrillation history of liver disease visual changes photophobia sudden onset altered sensation headache weakness sensory loss (...) aphasia dysarthria ataxia history of haematological disorder vertigo nausea/vomiting altered level of consciousness/coma confusion gaze paresis hypertension advanced age male sex Asian, black and/or Hispanic family history of haemorrhagic stroke haemophilia cerebral amyloid angiopathy autosomal dominant mutations in the COL4A1 gene hereditary haemorrhagic telangiectasia autosomal dominant mutations in the KRIT1 gene autosomal dominant mutations in the CCM2 gene autosomal dominant mutations

2018 BMJ Best Practice

35. Ischaemic stroke

=bestpractice.com This replaced the former definition of focal neurological impairment lasting less than 24 hours. History and exam vision loss or visual field deficit weakness aphasia impaired co-ordination (ataxia) history of transient ischaemic attack (TIA) sudden onset of symptoms negative symptoms (i.e., loss of function) altered sensation headache diplopia sensory loss dysarthria gaze paresis arrhythmias, murmurs, or pulmonary oedema vertigo/dizziness nausea and/or vomiting neck or facial pain miosis (...) , ptosis, and facial anhidrosis (hemilateral) altered level of consciousness/coma confusion older age family history of stroke history of ischaemic stroke hypertension smoking diabetes mellitus atrial fibrillation comorbid cardiac conditions carotid artery stenosis sickle cell disease dyslipidaemia people with lower levels of education African-American or Hispanic ancestry poor diet and nutrition physical inactivity obesity alcohol abuse oestrogen-containing therapy illicit drug use migraine

2018 BMJ Best Practice

36. Hyperosmolar hyperglycaemic state

, weakness, weight loss, tachycardia, dry mucous membranes, poor skin turgor, hypotension, and, in severe cases, shock. Altered sensorium (lethargy, disorientation, stupor) is common and correlates best with effective serum osmolality. Coma is rare and, if seen, is usually associated with a serum osmolality >340 mmol/kg (>340 mOsm/kg) Treatment includes correction of fluid deficit and electrolyte abnormalities, and intravenous insulin. Definition Hyperosmolar hyperglycaemic state (HHS), also known as non (...) ?tool=bestpractice.com History and exam altered mental status polyuria polydipsia weight loss weakness dry mucous membranes poor skin turgor tachycardia hypotension seizures hypothermia shock abdominal pain focal neurological signs infection inadequate insulin or oral antidiabetic therapy acute illness in a known patient with diabetes nursing home residents postoperative state precipitating medications total parenteral nutrition (TPN) Cushing's syndrome hyperthyroidism acromegaly Diagnostic

2018 BMJ Best Practice

37. Coxiella burnetii infection

pregnancy has a specific clinical presentation (mostly asymptomatic), and may result in obstetric and fetal complications. Million M, Roblot F, Carles D, et al. Reevaluation of the risk of fetal death and malformation after Q fever. Clin Infect Dis. 2014 Jul 15;59(2):256-60. https://academic.oup.com/cid/article/59/2/256/2895572 http://www.ncbi.nlm.nih.gov/pubmed/24748522?tool=bestpractice.com Commonly known as Q fever. History and exam presence of risk factors abrupt onset of high fever flu-like illness (...) severe headache cough inspiratory crackles, rhonchi, or wheezing hepatomegaly exanthemas pleuritic chest pain seizures coma chronic fatigue signs of endocarditis or vascular infection (persistent focalised infection) other signs of persistent focalised infection other signs of acute infection exposure to infected animals occupational exposure travel or residency in endemic areas male gender age 30 to 70 years immunosuppression pre-existing cardiac disease pre-existing vasculopathy pregnancy

2018 BMJ Best Practice

38. Cerebral arteriovenous malformation

of arteriovenous malformations of the brain in adults. Brain. 2001;124:1900-1926. https://academic.oup.com/brain/article/124/10/1900/333474/A-systematic-review-of-the-frequency-and-prognosis http://www.ncbi.nlm.nih.gov/pubmed/11571210?tool=bestpractice.com History and exam presence of risk factors sudden-onset focal neurological deficit seizures reduced conscious level sudden-onset headache nausea vomiting confusion gradual-onset headaches hypertension coma gradual-onset focal neurological deficit cognitive

2018 BMJ Best Practice

39. Reye's syndrome

are lacking for a definitive cause-effect relationship. Usually presents after a preceding viral infection with acute onset of profuse vomiting and altered mental status ranging from a personality change to coma. Laboratory findings include elevated ammonia, ALT/AST, and prolonged PT, without an increase in bilirubin. Liver biopsy shows steatosis without significant inflammation. Treatment includes intensive supportive care, correction of metabolic abnormalities, and control of intracranial pressure (...) or cerebral oedema without inflammatory cell infiltrate; hepatic dysfunction documented by either a threefold elevation of serum transaminases and/or serum ammonia, or liver biopsy demonstrating fatty infiltration; there is no other diagnosis to account for the cerebral and hepatic derangement. History and exam presence of risk factors vomiting altered mental status hyperventilation hepatomegaly abnormal pupillary response hyper-reflexia/areflexia diminished pain response seizures absence of, or minimal

2018 BMJ Best Practice

40. Acute respiratory failure

without hypercapnia and with an arterial partial pressure of oxygen (PaO2) of <8 kPa (<60 mmHg) on room air at sea level. Hypercapnic respiratory failure (type 2 respiratory failure) is hypoxia with an arterial partial pressure of carbon dioxide (PaCO2) of >6.5 kPa (>50 mmHg) on room air at sea level. History and exam presence of risk factors direct trauma to the thorax and neck dyspnoea confusion tachypnoea accessory breathing muscle use stridor inability to speak retraction of intercostal spaces (...) cyanosis loss of airway/gag reflex anxiety headache hypoventilation cardiac rhythm disturbances underlying neuromuscular disorder drug use seizure coma asterixis papilloedema cigarette smoking young age elderly age pulmonary infection chronic lung disease upper airway obstruction lower airway obstruction alveolar abnormalities perfusion abnormalities cardiac failure peripheral nerve abnormalities muscle system abnormalities opiate and sedative medicines toxic fumes and gases traumatic spinal injury

2018 BMJ Best Practice

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