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Coma Exam

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141. Clinical Management of Stable Coronary Artery Disease in Patients With Type 2 Diabetes Mellitus: A Scientific Statement From the American Heart Association

, the efficacy and net clinical benefit of ticagrelor were more favorable among patients from THEMIS who had a history of percutaneous coronary intervention (PCI). Rivaroxaban The COMPASS trial (Cardiovascular Outcomes for People Using Anticoagulation Strategies) examined whether rivaroxaban improved cardiovascular outcomes in 27 395 patients with stable atherosclerotic vascular disease. Three strategies were tested: rivaroxaban 2.5 mg twice daily plus aspirin, rivaroxaban 5 mg twice daily, and aspirin alone (...) largely on the basis of these trials. , However, subsequent trials that specifically examined the role of a blood pressure lowering strategy to <130 mm Hg in patients with T2DM and hypertension found no substantive benefit of intensive blood pressure control in reducing the risk of coronary events, although there was evidence for decreased risk of stroke. , The observed stroke reduction is consistent with observational data that have shown a linear relationship between systolic blood pressure and risk

2020 American Heart Association

142. Triage of Scarce Critical Care Resources in COVID-19: An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians

, with greater variability and less accuracy at lower scores than at higher scores, and is not immediately applicable to all disease states: a patient with sepsis may have a SOFA score of 4 and a low mortality risk, for example, whereas a patient with an intracranial hemorrhage and a Glasgow Coma Scale score of 3 could share this SOFA score of 4 but have a very high risk of death. Potentially subjective elements, such as the dose of vasopressor administered or the assessment of Glasgow Coma Scale during (...) actions in the HCMC Crisis Care Annex which should be referred to for further details. Triage team documents decision-making in affected patient charts according to incident-specific template. Decision communicated to patient’s Attending MD and Inpatient Supervisor. Attending MD may make clinical appeal within 15 minutes if new clinical information suggest improvement (Triage Team – Reevaluates in light of new information and communications decision) IC directs Clinical Care Committee (CCC) to examine

2020 American College of Chest Physicians

143. Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age

. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (...) (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria ® Radiation Dose Assessment Introduction document [76]. ACR Appropriateness Criteria ® 10 Nuchal Translucency Evaluation Relative Radiation Level

2020 American College of Radiology

144. Seizures-Child

trauma as indicated by Glasgow coma scores of 13-15. In this study, although CT results were negative in 53% of patients, 7% of patients had lesions that required surgical intervention. MRI is generally less appropriate in the acute trauma setting, depending on the overall clinical status of the child. However, it can be useful in detecting intracranial blood as well as post-traumatic gliosis. An important subgroup to consider for CT evaluation is the patient younger than age 2 presenting (...) ), are considerably higher than those from imaging of patients with generalized seizures whose neurologic examination is normal [20,21]. In a study by Jan et al [22], neuroimaging was positive in more than 50% of patients whose seizures had focal features. MRI was considerably more sensitive than CT. Young et al [23] noted a 50% positivity rate for CT when neurologic findings were focal. Ibrahim et al [24] found seizures to be the presenting symptom in 12% of 81 consecutive children with primary brain tumors

2020 American College of Radiology

146. Unhealthy Drug Use: Screening

use can cause many serious health effects that vary by drug type, administration mode, amount, and frequency of use, as well as pregnancy status. Opioid use can cause drowsiness, slowed breathing, constipation, coma, and fatal overdose. Stimulants such as cocaine can cause arrhythmias, myocardial infarction, seizures, and other complications. Marijuana use is associated with slowed reaction time; problems with balance, coordination, learning, and memory; and chronic cough and frequent respiratory (...) . The American Academy of Pediatrics recommends screening adolescents through their early 20s for substance use (including tobacco and alcohol) at every annual physical examination as well as screening adolescents who present to emergency departments or urgent care centers; report cigarette smoking; have depression, anxiety, or other mental health conditions associated with substance abuse; or exhibit school, legal, or social problems or other behavioral changes. It provides a list of screening tools

2020 U.S. Preventive Services Task Force

147. 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

2018 BMJ Best Practice

148. South American haemorrhagic fevers

. Viral hemorrhagic fevers (VHFs): Old World/New World arenaviruses. June 2013 [internet publication]. http://www.cdc.gov/vhf/virus-families/arenaviruses.html History and exam presence of risk factors fever ≥37.5°C bleeding (gums, epistaxis, gastrointestinal, metrorrhagia) petechiae conjunctivitis malaise headache arthralgia myalgia abdominal pain nausea/vomiting diarrhoea lymphadenopathy neurological symptoms (e.g., confusion, ataxia, seizures) sore throat cough prostration/coma occupational exposure

2018 BMJ Best Practice

149. Lassa fever

and death. History and exam presence of risk factors fever ≥37.5°C elevated respiratory rate low systolic blood pressure malaise nausea/vomiting headache sore throat/pharyngitis conjunctivitis chest pain/cough myalgia deafness (sensorineural) facial oedema bleeding abdominal pain diarrhoea confusion and altered Glasgow Coma Scale or seizures effusions occupational exposure living/working in, or arrival from, endemic area contact with infected body fluids butchering and/or eating rodent meat bioterrorism

2018 BMJ Best Practice

150. Hyponatraemia

of hyponatraemia.) This topic principally focuses on hypotonic (hypo-osmolar) hyponatraemia, the most common type of hyponatraemia. History and exam presence of risk factors high fluid intake fluid losses history of diabetes mellitus history of cirrhosis, nephrosis, congestive heart failure nausea/vomiting mild cognitive symptoms altered mental status, seizures, coma low urine output weight changes orthostatic hypotension abnormal jugular venous pressure poor skin turgor dry mucous membranes absence

2018 BMJ Best Practice

151. 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

152. 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

153. 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

154. 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

155. Overview of acid-base and electrolyte disorders

bicarbonate retention and loss, respectively; metabolic acidosis and alkalosis are accompanied by compensatory hyperventilation and hypoventilation, respectively. Mixed metabolic disorders can occur (e.g., diabetic ketoacidosis complicated by vomiting), and evaluation depends on clinical history and examination, assessment of anion gap, serum electrolytes, and arterial blood gases. These disorders can be effectively evaluated by a stepwise pathophysiological approach. Berend K, de Vries AP, Gans RO (...) , pseudohypoparathyroidism, vitamin D deficiency, magnesium imbalance, hyperphosphataemia, hungry bone syndrome, acute pancreatitis, extensive osteoblastic skeletal metastases, chelating agents (e.g., citrate, EDTA, lactate, foscarnet), drug-induced, and use of gadolinium-based magnetic resonance imaging (MRI) contrast agents. It is also seen in critically ill patients. Symptoms from calcium elevation are typically not found unless the calcium is above 3 mmol/L (12 mg/dL). Severe hypercalcaemia symptoms and coma

2018 BMJ Best Practice

156. 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

157. 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

158. Overview of substance use disorders and overdose

cause coma and respiratory depression. Acute management consists of maintaining airway, respiration, and haemodynamic support while excluding other diagnoses. Assisted ventilation may be necessary. Death is uncommon. Tricyclic antidepressants have a narrow therapeutic index and therefore become potent cardiovascular and CNS toxins in moderate doses. Best markers for suspected overdose are a history of depression, suicidality, and overdose, with a sudden deterioration in mental status and vital signs (...) presentation. Initial presentation with coma and severe metabolic acidosis is rare. Alcohol dependence is a chronic, relapsing disorder that results from a variety of genetic, psychosocial, and environmental factors. Swift RM. Drug therapy for alcohol dependence. N Engl J Med. 1999 May 13;340(19):1482-90. http://www.ncbi.nlm.nih.gov/pubmed/10320388?tool=bestpractice.com It is characterised by increased tolerance to the effects of alcohol, the presence of characteristic withdrawal signs and symptoms

2018 BMJ Best Practice

159. 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

160. 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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