copy of neurology 2011

8/2/2019 Copy of Neurology 2011

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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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