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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
Trauma present?
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.
Vital Signs
Extreme hypertension
Reversible posterior leukoencephalopathy
Hypertensive encephalopathy
Hypertensive intracerebral/cerebellar/brainstem hemorrhage
Intracranial hypertension/stroke
Hypotension: could reflect circulatory failure
Sepsis,
also presents
with hypothermia
Hypovolemia
Cardiac failure
Addison's disease
Certain drugs
Hypothermia
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
Hyperthermia
Heat stroke
Anticholinergic intoxication
Infection
Malignant hyperthermia,
also presents with
reflex posturing
Ventilation
Hyperventilation: lesions of pons/midbrain
Hypoventilation
Cheyne-Stokes respiration => impaired cardiac output or bicerebral dysfunction
Absence of spontaneous breathing/ataxic breathing => medullary lesions
Others
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
Neurological examination
Eyes
Unilateral dilated un-reactive pupil, asymmetric eye movements => Herniation syndrome/stroke. Other signs: hypertension, bradycardia and irregular respiration.
Pinpoint pupils
Pontine damage from hemorrhage/infection
Sedatives e.g. opioids; barbiturates; hypothermia, bradycardia, hypotension, bradypnea
Organophosphate exposure
Spontaneous roving eye movements => Metabolic encephalopathy; cortical depression with intact brainstem.
Motor responses
Asymmetric => Herniation syndrome/stroke
Muscle tone
Asymmetric => contralateral cerebral hemisphere/upper brainstem lesion