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Coma Exam

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381. Meningitis - bacterial meningitis and meningococcal disease

mental state (confusion, delirium and drowsiness, impaired consciousness), non-blanching rash, back rigidity, bulging fontanelle (in children younger than 2 years of age), photophobia, Kernig's sign, Brudzinski's sign, coma, paresis, focal neurological deficit, and seizures. All suspected cases of meningitis are medical emergencies requiring immediate hospital admission by telephoning 999. For suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia (...) , a systematic review reported a number of prognostic factors to be statistically significant in more than one study of moderate or high quality [ ]: These include symptoms lasting more than 48 hours before admission, coma/impaired consciousness, prolonged seizures, prolonged fever, shock, peripheral circulatory failure, respiratory distress, absence of petechiae, young age, and Streptococcus pneumoniae being the causative organism. However, due to significant heterogeneity between the studies

2019 NICE Clinical Knowledge Summaries

382. Chronic obstructive pulmonary disease

in adults in the CKS topic on . In addition, the presence of airflow obstruction must be confirmed by post-bronchodilator . On examination there may be: Cyanosis. Raised jugular venous pressure (may indicate the presence of ). Cachexia. Hyperinflated chest. Use of accessory muscles. Pursed lip breathing. Wheeze or quiet breath sounds. Peripheral oedema (may indicate the presence of ). Consider and be aware that COPD may co-exist with other conditions. Consider the possibility of alpha1-antitrypsin

2019 NICE Clinical Knowledge Summaries

383. Dementia

capacity is available from the British Medical Association (BMA) website ( ). Assess cognition: Use a standardized such as the Mini-Mental state Examination (MMSE), the 6-item Cognitive Impairment Test (6-CIT), the General Practitioner Assessment of Cognition (GPCOG), or the 7-Minute Screen. Take into account factors known to affect performance (such as educational level, prior level of functioning, language, sensory impairment, and physical or mental health problems) when interpreting scores (...) to communicate verbally — may lead to attempts to communicate needs in other ways that can be seen as BSPD. Emotional upset of the carer (such as stress or depression). Communication difficulties between the carer and the person — may lead to anger or shouting. Environmental issues such as clutter, changes to the environment, over or under stimulation (lack of anything interesting to look at, excess noise and/or people), and lack of an established routine. Examine the person looking for: Focal neurological

2019 NICE Clinical Knowledge Summaries

384. Opioid dependence

. Social history — family problems, unemployment, accommodation issues, financial problems. On physical examination, there may be evidence of poor nutrition, dental caries, other signs of neglect, needle tracks, skin abscess, and signs of drug intoxication or withdrawal. On mental health assessment, there may be indications of abnormal general behaviour, disorders of mood (particularly anxiety or low mood), delusions or hallucinations, confusion. Basis for recommendation Basis for recommendation (...) . Confirm the person is taking psychoactive substances (based on history, examination and drug testing, and through accessing any relevant additional information from clinical records). Identify the degree of problem use or dependence. Identify physical and mental health problems. Identify social problems. Assess the family history for substance use and dependence and relevant medical, psychiatric or psychosocial factors. Determine the person's understanding of treatment options and motivation

2019 NICE Clinical Knowledge Summaries

385. Pelvic inflammatory disease

tenderness (usually bilateral). Adnexal tenderness (with or without a palpable mass), cervical motion tenderness, or uterine tenderness (on bimanual vaginal examination). Abnormal cervical or vaginal mucopurulent discharge (on speculum examination). A fever of greater than 38°C, although the temperature is often normal. Before managing for PID: Pregnancy should be ruled out. Other causes of lower abdominal pain in a young woman (such as acute appendicitis; endometriosis; irritable bowel syndrome; ovarian (...) primary healthcare professionals to: Recognize the clinical features of pelvic inflammatory disease (PID) promptly. Assess and examine a woman with suspected PID. Arrange investigations to confirm the diagnosis and to test for other sexually transmitted infections and genital infections. Prescribe appropriate treatment in the primary care setting. Ensure that sexual partners of women with PID are traced and managed appropriately. Refer to secondary care or other specialist services as required

2019 NICE Clinical Knowledge Summaries

386. Hyperthyroidism

[ ]. Thyroid storm (thyrotoxic crisis), which is rare and potentially life-threatening, and may occur after trauma, childbirth, surgery, infection, or stroke, for example (in people with untreated or suboptimally treated hyperthyroidism) [ ]. Clinical features include tachycardia, fever, atrial fibrillation, heart failure, fever, diarrhoea, vomiting, dehydration, jaundice, agitation, delirium, and coma [ ; ]. Atrial fibrillation — the risk of developing atrial fibrillation increases with decreasing levels (...) the section on for more information. Goitre (may be diffuse, multinodular, or single nodule). Examine the thyroid gland to assess its size, tenderness, symmetry, and nodularity. In , the thyroid gland is usually diffusely enlarged and the pyramidal lobe is often palpable, and there may be a bruit. Typically, the gland is soft and symmetrical, but may be firm with an irregular surface (bosselation). In some people, the thyroid gland may not be palpable. Non-tender thyroid nodules suggest . A unilateral non

2019 NICE Clinical Knowledge Summaries

387. Gastroenteritis

. Gastroenteritis is characterized by sudden onset of diarrhoea, with or without vomiting. Other symptoms include blood or mucus in stool, and fever or malaise. The diagnosis of gastroenteritis is usually made on the basis of clinical symptoms and signs, but examination and culture of a stool sample may be necessary to determine the cause. Alternative diagnoses include non-gastrointestinal infections, gastrointestinal conditions such as irritable bowel syndrome, adverse drug reaction or laxative abuse (...) ? Diarrhoea (loose or watery stools, usually at least three times in 24 hours) is the main symptom of gastroenteritis. Other symptoms may include: Nausea. Sudden onset of vomiting. Blood or mucus in stool. Systemic features (for example fever or malaise). The diagnosis of gastroenteritis is usually made on the basis of clinical symptoms and signs. Diagnostic investigations are rarely needed, but examination and culture of a stool sample may be necessary to determine the cause. Consider an if any

2019 NICE Clinical Knowledge Summaries

388. LUTS in men

and the sensation of incomplete emptying. Examination should be guided by urological and other symptoms, and should include: Examination of the abdomen for signs of a distended bladder, such as abdominal distention and suprapubic dullness on percussion. A check of the external genitalia to identify conditions which may cause or contribute to LUTS, for example phimosis, meatal stenosis, or penile cancer. A digital rectal examination to assess the prostate for size, consistency, nodules, and tenderness (...) . Examination of the perineum and/or lower limbs to evaluate motor and sensory function. Investigations should be guided by the symptoms, history, and examination. A dipstick test of the urine to check for blood, glucose, protein, leucocytes, and nitrites. Serum creatinine and estimated glomerular filtration rate (eGFR) should be measured if clinically indicated. Prostate specific antigen (PSA) testing should be done only after discussing the indications for the test and the interpretation and implications

2019 NICE Clinical Knowledge Summaries

389. Neutropenic sepsis

-morbidities, central venous access device, recent fungal infection, previous hospital admissions, or surgery. Any recent travel, infectious contacts, or animal exposure. Previous episodes of febrile neutropenia or sepsis. Examine the person to assess for: General appearance, level of consciousness, and cognition. Consider using the Glasgow Coma Scale (GCS) or AVPU ('alert, voice, pain, unresponsive') scale, to assess level of consciousness. Temperature. Be aware that people with neutropenic sepsis may (...) which help to stratify neutropenic patients regarding the risk of serious infection including invasive fungal infection is based on the ESMO clinical guidelines, the German Society of Hematology and Medical Oncology guidelines, and expert opinion in review articles [ ; ; ]. Assessing clinical features on examination The NICE clinical guideline on sepsis provides possible clinical features of sepsis, and notes that some people with sepsis are less likely to present with fever, including the elderly

2019 NICE Clinical Knowledge Summaries

390. Public Health Interventions to Reduce the Secondary Spread of Measles

allowed for calculation of the relative risk of contracting the disease between treated and untreated groups, whereas the matched case-control study allowed for calculation of the odds of vaccine recipients contracting measles as compared with people who did not receive the vaccine. Immunoglobulin for susceptible measles contacts One retrospective cohort study addressed this strategy: a 2009 report from Australia that also examined the strategy of vaccinating susceptible measles contacts, as described (...) , and probable measles cases; possible cases were excluded from the analysis. Isolation of communicable measles cases No studies were located that met the inclusion criteria and examined the effectiveness of this strategy. Public Health Interventions to Reduce the Secondary Spread of Measles 10 Targeted measles vaccination activities during an outbreak One retrospective cohort study addressed a special vaccination initiative 19 in which infants aged six to 11 months were immunized during a local measles

2015 Canadian Agency for Drugs and Technologies in Health - Rapid Review

391. Legal and Ethical Issues related to Resuscitation

may not be given without consent if the provider knows or could be reasonably expected to know that the victim objects to the care. The care given and the reasons must be certified in the clinical records (GAA s64). Care defined as health care does not include first-aid treatment, or non-intrusive examination for diagnostic purposes (e.g. visual examination of mouth, throat, nasal cavity, eyes or ears) or administration of a pharmaceutical drug which is non-prescriptive, normally self-administered (...) that: the opinion is supported by the written opinion (if practicably obtainable) of another medical practitioner who has examined the victim; the victim has not refused consent; and the medical practitioner has enquired whether the victim (if 16 years or over) has given an advance directive. However, a medical practitioner may treat a victim despite an advance care directive if reasonably believing that the directive is not intended to apply to treatment of the kind proposed and to the circumstances

2015 Australian Resuscitation Council

392. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. (Full text)

Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. Diabetic ketoacidosis in children may cause brain injuries ranging from mild to severe. Whether intravenous fluids contribute to these injuries has been debated for decades.We conducted a 13-center, randomized, controlled trial that examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis. Children were randomly (...) assigned to one of four treatment groups in a 2-by-2 factorial design (0.9% or 0.45% sodium chloride content and rapid or slow rate of administration). The primary outcome was a decline in mental status (two consecutive Glasgow Coma Scale scores of <14, on a scale ranging from 3 to 15, with lower scores indicating worse mental status) during treatment for diabetic ketoacidosis. Secondary outcomes included clinically apparent brain injury during treatment for diabetic ketoacidosis, short-term memory

2018 NEJM Controlled trial quality: predicted high PubMed abstract

393. Detecting delirium in patients with acute stroke: a systematic review of test accuracy. (Full text)

have been studied as: The Abbreviated Mental Test-10, the Abbreviated Mental Test short form, the Clock Drawing Test, the Cognitive Examination derived from the National Institutes of Health Stroke Scale and the Glasgow Coma Scale. Moreover, the use of a single question-namely, 'Does this patient have cognitive issues?' as answered by the multidisciplinary team-has been subjected to a validation process.To date a few primary studies have been published to test the accuracy of tools in their ability

2020 BMC neurology PubMed abstract

394. Risk factors for pneumonia in patients with anti-NMDA receptor encephalitis: A single-center retrospective study. (Full text)

Risk factors for pneumonia in patients with anti-NMDA receptor encephalitis: A single-center retrospective study. To identify the risk factors of pneumonia in patients with Anti-N-methyl-D-aspartate (Anti-NMDA) receptor encephalitis.This is a retrospective study.Department of Neurology in West China Hospital of Sichuan University.Patients with a definitive diagnosis of anti-NMDA receptor encephalitis.Risk factors associated with pneumonia were examined by bivariate analysis and multivariate (...) logistic regression model.A total of 104 patients were included in this study, of which 41% patients (n = 43) were diagnosed with pneumonia at 7 days (range: 4-40 days) after admission. The occurrence of pneumonia was associated with prolonged hospital stays, a higher rate of poor outcome, and extra healthcare costs. Risk factors associated with pneumonia included Glasgow coma scale score (GCS), abnormal movements and hypokalemia.Pneumonia is a common complication in anti-NMDA receptor encephalitis

2020 Medicine PubMed abstract

395. Apoptosis in cerebrospinal fluid as outcome predictors in severe traumatic brain injury: An observational study. (Full text)

Apoptosis in cerebrospinal fluid as outcome predictors in severe traumatic brain injury: An observational study. Traumatic brain injury (TBI), due to its high mortality and morbidity, is an important research topic. Apoptosis plays a pathogenic role in a series of neurological disorders, from neurodegenerative diseases to acute neurological lesions.In this study, we analyzed the association between apoptosis and the Glasgow Outcome Scale (GOS), to examine the potential of apoptosis (...) as a biomarker for a TBI outcome. Patients with severe TBI were recruited at the Department of Neurosurgery, Wujin Hospital Affiliated with Jiangsu University, between January 2018 and December 2019. As a control group, healthy subjects were recruited. The concentrations of caspase-3, cytochrome c, sFas, and caspase-9 in the cerebrospinal fluid (CSF) were analyzed by enzyme-linked immunosorbent assay (ELISA). The association between the GOS and the clinical variables age, sex, initial Glasgow Coma Scale (GCS

2020 Medicine PubMed abstract

396. Elevated blood alcohol impacts hospital mortality following motorcycle injury: A National Trauma Data Bank analysis. (Full text)

to 2014. Patients ≥ 18 years of age who sustained a traumatic injury following a motorcycle accident with a confirmed blood alcohol test at the time of arrival to the hospital were included. Other variables examined were: sex, race, injury severity score (ISS), and initial Glasgow Coma Scale motor score (GCSMOT), systolic blood pressure (SBP, mm Hg), SBP <90, and comorbidities. Patients with a blood alcohol concentration (BAC) at or beyond the legal limit (0.08 g/dL) comprised the "alcohol positive

2020 Injury PubMed abstract

397. Torso injuries after fall from standing-empiric abdominal or thoracic CT imaging is not indicated. (Full text)

exam had a negative predictive value of 99.7% for intervention, but when combined with vital signs, the value was 100%.Torso injuries in FFS are rare. Of our study population, 13 abdominal injuries underwent intervention, and 11 chest injuries underwent intervention. Screening patients by physical examination and vital signs is sufficient and safely allows for the use of selective abdominal and chest CT.Copyright © 2019 Elsevier Ltd. All rights reserved. (...) Torso injuries after fall from standing-empiric abdominal or thoracic CT imaging is not indicated. Falls from standing (FFS) have become the most common mechanism of injury at many trauma centers. Liberal imaging of low energy trauma has questionable value. We hypothesize that torso trauma intervention is rare in the FFS population, and physical examination sufficiently screens for torso injuries needing intervention.We queried our ACS-verified Level 1 trauma center registry for falls from

2020 Injury PubMed abstract

398. Risk of severe acute kidney injury in multiple trauma patients: Risk estimation based on a national trauma dataset. (Full text)

Risk of severe acute kidney injury in multiple trauma patients: Risk estimation based on a national trauma dataset. The development of acute kidney injury (AKI) in trauma patients has been associated with almost three fold increase in overall mortality. However, there is a paucity of information of early recognition of risk factors of severe AKI in trauma patients examining the patient's demography, injury characteristics and comorbidities. The purpose of the study was early identification (...) of risk factors of severe AKI.This retrospective cohort study was performed using 2012-2016, American College of Surgeon Trauma Quality improvement program (ACS-TQIP) data, a national data base of trauma patients in the United State. All adult Trauma patients, age 16 to 89 years old, admitted to the hospital were included in the study. Other variables included; race, sex, initial systolic blood pressure (SBP), SBP<90 mmHg, heart rate, injury severity score (ISS), Glasgow Coma Scale Motor Score (GCSMOT

2020 Injury PubMed abstract

399. Mild and Moderate Traumatic Brain Injury and Gender-Based Critical Care Outcomes. (Abstract)

Mild and Moderate Traumatic Brain Injury and Gender-Based Critical Care Outcomes. Traumatic brain injury (TBI) is a major contributor to death and complications. Previous studies have identified gender disparities among trauma patients. This study aims to examine the association between gender and outcomes in TBI patients.Review of our trauma registry: Patients were classified into groups according to their gender. Demographics extracted from the registry included age, injury severity score (...) (ISS), Glasgow Coma Score (GCS), head abbreviated injury score (AIS), and the presence of an epidural hematoma (EDH). The primary outcome was mortality; secondary outcomes included ICU length of stay (ICU-LOS), craniotomy rate, ventilator-associated pneumonia (VAP), and readmission rates. Significance was defined as p < 0.05.Nine hundred and thirty-five patients with TBI were studied: 62.1% (n = 581) were male and 37.9% (n = 354) were female. There were no differences in GCS, ISS, and head AIS

2020 World Journal of Surgery

400. Predictors of New-Onset Physical Restraint Use in Critically Ill Adults. (Abstract)

care medical center in the United States. Use of physical restraints was determined via daily in-person assessments and medical record review. Mixed-effects logistic regression analysis was used to examine factors associated with new-onset use of physical restraints, adjusting for covariates and within-subject correlation among intensive care unit days.Of 145 patients who were free of physical restraints within 48 hours of intensive care unit admission, 24 (16.6%) had restraints newly applied (...) during their stay. In adjusted models, delirium (odds ratio [OR], 5.09; 95% CI, 1.83-14.14), endotracheal tube presence (OR, 3.47; 95% CI, 1.22-9.86), and benzodiazepine administration (OR, 3.17; 95% CI, 1.28-7.81) significantly increased the odds of next-day use of physical restraints. Tracheostomy was associated with significantly lowered odds of next-day restraint use (OR, 0.13; 95% CI, 0.02-0.73). Compared with patients with a target sedation level, patients who were in a coma (OR, 2.56; 95% CI

2020 American Journal of Critical Care

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