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35 year old man - unconscious, found slumped on pub sofa (Asymmetrical,…

- - - - TTP, DIC, cerebral bleeding
    - - brainstem infarcts/hemorrhage
- - - - Cerebral venous thrombosis: intractable worsening headache of subacute onset, often associated with nausea and vomiting, seizures common; Exam: papilloedema; venous infarction: focal neurology, such as hemiplegia
    - - Basilar artery thrombosis: commonly vision loss and photopsia; Exam: often quadriparesis, pseudobulbar palsy, papillary and ocular palsies
  - - - Common: Alcohol abuse: hx of harmful use of alcohol and alcohol dependence; tolerance; withdrawal; impaired control of drinking behaviour; continued alcohol use despite adverse consequences; Exam: odour of alcoholic beverage on breath, stigmata of liver disease in chronic alcoholics. Overdose (opiates, tricyclics, benzodiazepines)
        Less common: CO
    - - Common: Hypoglycemia: cold perspiration, confusion, multi-focal or generalised seizures, light-headedness, or agitation preceding loss of consciousness; Exam: tachycardia, higher BP. Diabetic ketoacidosis: patients with type 1 diabetes, particularly in the setting of concomitant illness such as infection or MI; Exam: confused, drowsy, smell of ketones on breath. Less common: Hypothermia:coma preceded by delirium and then stupor as temperature drops; may be accidental; may be a hx of hypothalamic disorder, spinal cord injury, hypothyroidism, adrenal failure, Wernicke's encephalopathy, advanced sepsis, sedative drug intoxication; Exam: core body temperature 35°C (95°F); 28°C (82.4°F) usually causes coma; pupillary light reflex absent, resembling brain death. Hyperglycemia: increased diuresis, progressive confusion, hx of diabetes mellitus, sub-optimal insulin therapy, seizures; Exam: clinical dehydration, tachycardia, hypotension; DKA: Kussmaul's breathing, acetone breath. Hepatic encephalopathy: underlying hepatic failure, alcoholism, intravenous drug abuse, paracetamol overdose; malaise, confusion/delirium, agitation, progressive impairment of consciousness from stupor to coma; chronic liver disease: decompensation often due to intercurrent infection, sedative drugs, excessive diuresis or constipation; Exam: ascites, spider nevi, dilated peri-umbilical veins, ± jaundice, tremor, increased tone, asterixis, Kayser-Fleischer rings (crescentic, rusty-brown discoloration in the limbus of the corneae, especially in young patients). Uremia (renal failure). Rarer: Hypoxia, Hypercapnia, Hypernatremia. Hypercalcemia, Hypocalcemia, Hypermagnesemia, Hyperthermia. Reye's encephalopathy, Aminoacidemia, Porphyria, Dialysis encephalopathy, Addisonian crisis, Hypothyroidism: coma, hypothermia. Wernicke's encephalopathy: hx of alcoholism, malnutrition, gastric stapling, or patients requiring haemodialysis (not taking supplemental B vitamins); Exam: absent vestibulo-ocular reflexes in hypothermic patient with preserved pupillary reflexes is a major clue.
    - - Less common: Bacterial meningitis, Viral encephalitis. Rarer: Postinfectious encephalomyelitis, Syphilis, Sepsis, Typhoid fever, Malaria, Waterhouse-Friderichsen syndrome
    - - Catatonia
    - - Common: 2. Cardiac arrest: sudden collapse, may be preceded by chest pain; Exam: absent carotid pulse. Epileptic seizure: transient coma; prodromal symptoms including diaphoresis, nausea, dimming of vision, and tinnitus; convulsive movements and incontinence can occur; usually followed by confusion and drowsiness that often lasts ≥10 minutes; Exam: convulsive: bilateral synchronous convulsions, open eyes; non-convulsive: no convulsions, infrequently nystagmoid eye movements, or bilateral facial twitching. Less common: fat embolism, Hypertensive encephalopathy, Hypothyroidism, Nonconvulsive status epilepticus, Heat stroke