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Coma Exam

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161. Rabies

countries including the US. The World Health Organization (WHO) has set a global goal to achieve no human deaths from dog-transmitted rabies by 2030. World Health Organization. Zero by 30: the global strategic plan to end human deaths from dog-mediated rabies by 2030. June 2018 [internet publication]. http://www.who.int/rabies/resources/9789241513838/en/ History and exam presence of risk factors hydrophobia aerophobia limb numbness, pain, and paraesthesia pruritus dysphagia fever change in behaviour (...) agitation and confusion hallucination signs of autonomic instability rapid progression of symptoms weakness and paralysis urinary or faecal incontinence coma abdominal pain insomnia seizures slurred or stuttered speech ataxia recent scratch or bite from a known vector travel to/living in rabies-endemic country occupational or recreational exposure age <15 years Diagnostic investigations saliva PCR and viral culture skin biopsy (neck) with direct fluorescent antibody (DFA) and PCR CSF cytology CSF

2018 BMJ Best Practice

162. 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

163. 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

164. 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

165. Primary hypothyroidism

Med. 2001;345:260-265. http://www.ncbi.nlm.nih.gov/pubmed/11474665?tool=bestpractice.com Myxoedema coma is a rare severe form of hypothyroidism with multi-organ failure. Franklyn JA. Hypothyroidism. Medicine. 2005;33:27-29. History and exam presence of risk factors weakness lethargy cold sensitivity constipation weight gain depression menstrual irregularity myalgia dry or coarse skin eyelid oedema thick tongue facial oedema coarse hair bradycardia deep voice diastolic hypertension with or without (...) Primary hypothyroidism Primary hypothyroidism - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Primary hypothyroidism Last reviewed: February 2019 Last updated: June 2018 Summary Patients usually present with non-specific symptoms of weakness, lethargy, depression, and mild weight gain. Commonly, disease is sub-clinical. Physical examination may show dry skin, thick tongue, eyelid oedema, and bradycardia. Elevated TSH

2018 BMJ Best Practice

166. 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 (...) examination before feeding. Anaesthesia-related aspiration of gastric contents can be prevented by identifying patients susceptible to vomiting and reflux, minimising gastric contents before surgery, minimising emetic stimuli, and avoiding complete loss of protective reflexes from over-sedation. Antibiotics are not indicated early after aspiration of gastric contents, but they should be considered if the pneumonitis does not resolve after 48 hours. Patients with neurological deficits, infants, older

2018 BMJ Best Practice

167. Rocky Mountain spotted fever

=bestpractice.com Detailed content on other rickettsial infections is covered by our separate Rickettsial Diseases topic. History and exam known recent tick exposure or bite triad of fever, rash, and history of tick exposure triad of fever, rash, and headache fever rash headache nausea/vomiting myalgia altered mental status abdominal pain residence in or recent exposure to rural area diarrhoea conjunctivitis lymphadenopathy peripheral oedema meningismus splenomegaly hepatomegaly jaundice seizures shock coma

2018 BMJ Best Practice

168. 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

169. 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

170. 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

171. Electrical injury

no injury. May cause electrical and thermal burns, and secondary injuries due to a fall, severe tetany, or the force of electrical blast. Survivors of high-voltage electrical injury or lightning strikes can suffer long-term sequelae, and regular follow-up is essential. Definition Electrical injuries may be caused by exposure to natural lightning or electricity in the home or workplace. Electrical injury includes electrocution, electric shock, burns, and secondary injuries. History and exam presence (...) of risk factors loss of consciousness pre-hospital CPR or defibrillation tachycardia hypotension low Glasgow coma score burns physical injuries diminished peripheral pulses and poor capillary refill low core body temperature confusion paralysis age <6 years construction industry workers male Diagnostic investigations ECG FBC electrolytes LFTs coagulation studies CK urine myoglobin cardiac enzymes (CK-MB and troponin) toxicology screen CXR plain x-rays head CT head MRI Treatment algorithm ACUTE

2018 BMJ Best Practice

172. Hypothermia

normal limits, typically <35°C (<95°F). History and exam presence of risk factors cold exposure and body temperature <35°C (<95°F) impaired mental state shivering frostbite tachypnoea, tachycardia, hypertension if mild hypothermia respiratory depression, bradycardia, hypotension if moderate hypothermia coma and apnoea if severe hypothermia cold-induced diuresis general anaesthetic use substance abuse impaired mental status hypothyroidism stroke Parkinson's disease neuroleptic medication beta-blocker

2018 BMJ Best Practice

173. 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

174. Assessment of delirium

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 (...) 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

2018 BMJ Best Practice

175. 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

176. Assessment of syncope

Guidelines, and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e60-122. https://www.ahajournals.org/doi/abs/10.1161/CIR.0000000000000499 http://www.ncbi.nlm.nih.gov/pubmed/28280231?tool=bestpractice.com It has many causes, and is distinct from vertigo, seizures, coma, falls, psychogenic pseudosyncope, drop attacks, transient ischaemic attacks, and states of altered consciousness. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF scientific statement on the evaluation of syncope: from (...) with or without heart disease. J Am Coll Cardiol. 2001 Jun 1;37(7):1921-8. https://www.sciencedirect.com/science/article/pii/S0735109701012414?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/11401133?tool=bestpractice.com Linzer M, Yang EH, Estes NA 3rd, et al. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. 1997 Jun 15;126(12):989-96. http://www.ncbi.nlm.nih.gov/pubmed

2018 BMJ Best Practice

177. 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

178. 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

179. 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

2018 BMJ Best Practice

180. 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

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