copy of neurology 2011
TRANSCRIPT
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Dr. Abeer M.Abdel Hamid Eissa.Lecturer of Internal Medicine.
Allergy & Immunology Department .
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Objectives
By the end of lecture ,you will be ableto: Perform 1st aid management for
comatose patient Set differential diagnosis for comatose
patient.
Care of comatose patient.
Enumerate causes of fits perform 1st aid management, perform needed
investigations for patients with convulsions
treat different conditions.
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COMA
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A
B
C
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DONT FORGET TO
Check!!!!!!!!!!Pulse & Respiration
Cyanosis
BPGlucose level
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In comatose patient
giveGlucose 10%
Thiamine
Naloxone
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Glasgow Coma Scale(prognostic)
Motor
6 obeying orders
5 localization4 withdrawal
3 flexion
2 extension1 non
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Speech
5 oriented
4 confused
3 inappropriate word
2 sounds
1 non
Eye
4 spontaneous opening
3 opening to speech
2 opening to pain
1 non
N.B: score 3-15 ,
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Differential diagnosis ofCOMA
By History and Examination
LateralizationNO
lateralization
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Lateralization
Primary
Neurological
Insult
No lateralization
1-Endocrinal2-Hepatic
3-Renal
4-Hypertensive encephalopathy
5-Meningitis,encephalitis
6-hypo/hyper Na(esp in elderly)
7-hypercalcemia
8-MI in elderly
9-Respiratoty failure
10-Infection in elderly)sepsis)11-Toxocological
12-shock
13-post-ectal
14-Hysterical
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MANAGEMENT
1-History of: CLD- CRF- chest troubles-DM- HTN
2-Vital data: Dont forget Temp
3-Full examination
4-Full Investigations
Any undiagnosed coma= CT brain
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INVESTIGATIONS
CT/MRI brain
CBC-LFT-RFT-RBS
electrolytes-Na-Ca
ABG
Fundus-Lumbar puncture
Thyroid profile
Toxicological screen-ECG
CXR
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Cases
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Case studyA young man is brought into the emergency
department by ambulance at 9 a.m. He wasdiscovered unconscious in bed by his flatmatethat morning. He had been seen at about 10p.m. the previous evening when he had been
well. The flatmate has not accompanied thepatient to the hospital but the ambulanceofficers relate that the flatmate said the patient
was previously healthy. The man appears to bein his twenties and is dressed in jeans and a T-shirt. He is still comatose.
What are you going to do immediately?
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The patient does not respond to pain and
has no gag reflex. He accepts an airwaywithout response. He is breathingspontaneously, his respiratory rate is 14
breaths per minute and he is notcyanosed. There are no obvious signs ofexternal injury. A high-flow oxygen mask is
applied.
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His pulse is 110 bpm and his bloodpressure is 100/60 mm Hg. An axillarytemperature is 37C. An intravenous line is
inserted. One nurse applies a cardiacmonitor. The other nurse measures hisblood sugar, which is 4.9 mmol/l (normal
range 4-8).
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An intravenous dose of naloxone (0.8 mg)is given and there is no response. Blood issent for complete blood count,
electrolytes, blood alcohol level and aparacetamol concentration. His oxygensaturation is 99% on 8 l/min oxygen.
Describe and justify what you should lookfor on examination?
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On examination the patient smells of alcohol.He has no spontaneous movements. There
are no needle tracks on his arms. Hisrespiration is shallow and regular. He has nogag reflex or response of any of his limbs to
painful stimuli. His pupils are mid-range,equal andreact sluggishly to light. Gaze isconjugate but there are no spontaneous eyemovements. The doll's eye or oculocephalic
reflex eye movements are absent .ThecorneaI reflexes are absent. The patient hasno neck stiffness.
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The limbs are hypotonic and the limbreflexes are difficult to elicit. There is noevidence of trauma to the head. The fundi
are normal. The remainder of theexamination is unremarkable.
What are the common causes of coma?
What are the likely causes in this patient?
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Case study:Presenting problem 74 year old man is brought to the ER, as he is
found confused, disoriented and delirious. Helives alone and he had not telephoned his familyfor 2 days, his son entered his apartment and
found him lying on the floor, covered with urineand stool. The patient is conversant butconfused and drowsy. He was a healthy manwith no previous medical problems. He doesnt
take any medications. He is a chronic cigarettesmoker (1 pack per year)and occasionally drinksalcohol.
What would your differential diagnosis includebefore examining the patient?
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Examination
Patient gives his name correctly
Patient is malnorished
Afebrile Mild central cyanosis
Dry tongue
HR 110 RR 24
BP130/70
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Optic fundi are normal with no papilledema
Trachea central Left side of chest moves less
Left side of chest is dull on percussion with
bronchial breathing Increase resistance to passive flexion of
neck
Cranial nerves, motor,sensory systemsare normal
Reflexes are normal
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Investigations
Hemoglobin 10g/dl WCC 16,000
NE 85%
LY 10%
Blood glucose 100mg/dl
Blood urea 30 mg/dl
S.creat 1 mg/dl
Na 128mmol/l
K 4.3 mmol/l
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ECG: doesnt suggest acute coronay
syndrome
CXR: homogenous opacity in left mid andlower zones
ABG:PO254mmHg,PCo2 34mmHg,O2saturation 89%,HCO3 21.9
CT brain: age changes related cerebralatrophy
Lumbar puncture: normal
Serological tests for Mycoplasma, Chlamydia,Legionella, common viral infections andsyphilis: negative
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Pneumococal antigen not detected inserum
Sputum culture sterile
Blood culture grows Haemophilusinfluenza sensitive to co-amoxiclav
Does this narrows your differentialdiagnosis?
How will you treat this patient?
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Care of comatose patient
Entubation :GCS
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1-airway2-oxygen supply(take care of cyanosis)3-Safe surrounding
4-IV line :IV diazepamIV epanutin:loading 15mg/kg ,
maintenance 7.5 mg /kg
IV glucose if hypoglycemiaIV Ca if hypocalcemia
Treatment of cause
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1) Neurological
Meningitis,encephaliyis,brain abcessTraumaInfarction
TumorHaemorrahgeEpliepsy
2)Other causes:
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2)Other causes:HTN encephalopathyHypo&Hyper NaHypo&Hyper glycemia
HypocalcemiaHypoMgHypoxiaRenal
EclampsiaVasculitisToxocologicalHysterical
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ABG,Na, Ca, Mg,glucose,s.creatinine,
CT brain,MRI brainlumbar puncture,Toxocological screenEEG.
Investigations :
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Cases references
Davidsons Clinical Cases.
Clinical Problems in General Medicine and
Surgery.
Thanks to:
MOSTAFA ABDEL RAAOUFFor sharing in designing
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