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35 yo man. Unconscious at a pub. (Symmetrical neurological findings (Toxic…
35 yo man. Unconscious at a pub.
Symmetrical neurological findings
Toxic
Psychoactive/anti-epileptic drugs (benzo)
more prominent miosis & brdaycardia, hypotension than opioid
Opioid poisoning (heroin..)
depressed RR (<12/min), rales (aspiration/ARDS), bowel sounds, hypothermia (hyperthermia suggest aspiration pneumonia/complications of drug)
constricted pupils, signs of trauma, needle marks/SSTI
Alcoholic intoxication
aspiration, vomit, penumonia, no miosis, no change in bowel sounds, hypotension, tachycardia
Acute labs: hypoglycemia, lactic acidosis, hypoMg/K/Ca/PO4
Structural - lesion involving brain-stem/diecncephalic arousal centers
Pontine damage - pinpoint pupile
Midbrain - enlarged & unreactive pupils
Cortical depression, intact brainstem - spontaneously roving eyes
Metabolic encephalopathies
tremor, asterixis, multifocal myoclonus, decreased muscle tone, pupils symmetrical & constricts with light
Hypoglycemia
history of diabetes, med (insulin, alcohol), hormone def (cortisol, glucagon), endogenous hyperinsulinism
DKA (within 24hr) v.s. HHS (insiduous)
Precede: polyuria, polydipsia, weight loss
hyperventilation & abdo pain, mental obtundation (more DKA)
Progress: focal neurological symptoms (more HSS)--> coma
volume depletion, fruity odor, kussmaul respi
Infection
Encephalitis
fever, N/V, HA
absence of meningeal irritation signs but often have seizures & focal neurological abnormalities e.g. increase reflex, CN palsies, hemiparesis
Meningitis
fever. Preceded by: nuchal rigidity, HA (severe & generalized), photophobia
neurological deficits: seizure, focal deficits, mental status change
Post-ictal state (epilepsy)
Vascular
Hypoperfusion
AMI
ischemic chest pain, diaphoresis , N/V, SOB, belching, clamminess, fatigue
tachycardia, cool, clammy, pale
Heart failure
dyspnea, orthopnea, edema, abdo distension, weakness more on exertion
JV distension, pulmonary crackles, tachycardia, MR murmur
Hypertensive encephalopathy
Hx of uncontrolled HTN, marked high BP, retinal hemorrhages, N/V followed by non-localizing neurologic symptoms
diagnosis of exclusion
Focal neurological findings:
unilateral dilated, un-reactive pupil
asymmetric eye movements
Chronic onset
Tumor (primary CNS/metastatic)
Generalized S/S: HA, seizures, N/V, syncope, cognitive dysfunction
focal S/S: weakness, sensory loss, aphasia, visual spatial dysfunction
Acute: Signs of Trauma
Diffuse axonal injury
profound coma without raised ICP
CT: looks normal, may have multiple focal lesions (at grey-white matter junction, corpus callosum)
Hematoma**
Preceded by N/V, drowsiness, confusion, aphasia, seizures, hemiparesis, nuchal rigidity
ipsilateral dilated pupils (due to uncal herniation), but if catch very late, both eyes can be dilated
cushing reflex (HTN. bradycardia. respiratory depression)
Subdural hematoma
gradually lose consciousness with increasing confusion
CT: crescenteric & more extensive than EpiHem, crosses sutures
Epidural hematoma
lucid interval after injury but with ongiong severe headache, gradually lose consciousness over next few hrs
CT: lentiform, do not cross sutures
Stroke
Ischemic stroke
depends on site of lesion, may include facial paresis, arm drift/weakness, abnormal speech