35-year-old man who was found unconscious on the sofa at a local pub…
35-year-old man who was found unconscious on the sofa at a local pub
General physical examination
Visible sign of trauma
Bruises => head trauma
"Raccoon eye" => Periorbital ecchymosis
Bruising over mastoid, blood behind tympanic membrane => basal skull fracture
Bullous lesions => barbiturate intoxication.
Tongue bitten on lateral aspect => recent convulsive seizure. Other signs: fractures, e.g. vertebral compression fractures with posterior fracture shoulder
No visible sign of trauma. Other signs
Petechiae and ecchymoses => possible infection e.g. meningococcal septicemia. Other signs: resistance to passive neck flexion (meningismus: similar to meningitis)
Jaundice => possible liver disease
Cherry red colour, e.g. lips and mucous membranes => CO intoxication
Pallor with sallow appearance => uremia, myxedema, severe anemia.
Reversible posterior leukoencephalopathy
Hypertensive intracerebral/cerebellar/brainstem hemorrhage
Hypotension: could reflect circulatory failure
Primary: hypothalamic dysfunction (Wernicke's encephalopathy or tumour)
Secondary: adrenal failure, hypothyroidism
Secondary: drug or alcohol intoxification. Check for needle tracks (IV drug abuse).
Also presents with
pupils in midposition and fixed
Hyperventilation: lesions of pons/midbrain
Cheyne-Stokes respiration => impaired cardiac output or bicerebral dysfunction
Absence of spontaneous breathing/ataxic breathing => medullary lesions
Perspiration => Hypoglycemia. Other signs: reflex posturing (involuntary flexion or extension of the arms and legs); symmetric neurological deficits, e.g. pupils appear abnormal but constrict symmetrically with light
also presents with
Unilateral dilated un-reactive pupil, asymmetric eye movements => Herniation syndrome/stroke. Other signs: hypertension, bradycardia and irregular respiration.
Pontine damage from hemorrhage/infection
Sedatives e.g. opioids; barbiturates; hypothermia, bradycardia, hypotension, bradypnea
Spontaneous roving eye movements => Metabolic encephalopathy; cortical depression with intact brainstem.
Asymmetric => Herniation syndrome/stroke
Asymmetric => contralateral cerebral hemisphere/upper brainstem lesion