Assessment of a Comatose Patient (50)

Case: A young patient is brought to ED with unconsciousness. His airway is patent and breathing without difficulty. His blood pressure is stable
and temperature is 37.5.

Tasks:

1. Examination and Commentary

2. Differential Diagnosis
3. Investigation you would like to arrange
4. Management

DISABILITY
1. AVPU/GCS:
1. EYE MOVEMENT:4
 The patient is spontaneously opening his eyes. His eye response is 4.
 Sir, can you please open your eyes? The patient opened his eyes when asked. The eye response is 3.
 On eliciting pain, the patient’s eye opened. The patient’s eye response is 2.
 The patient did not open his eyes when pain is elicited. The eye response is 1.
2. VERBAL RESPONSE:5
 Sir, what’s your name? Where are you? (Answered Ken. In the hospital): The patient’s verbal response is 5.
 Sir, what’s your name? Where are you?( Answered. Ken, home, I mean hospital). The patient’s verbal response is 4.
 Sir, what’s your name? Where are you? (Answered: Fuck). The patient’s verbal reponse is inappropriate and the
score is 3.
 Sir, what’s your name? Where are you? (Answered: mhunau). The patient’s verbal response is incomprehensible and
the score is 2.
 The patient has nor verbal response with a score of 1.
3. MOTOR RESPONSE:6
 Can you please bend your elbow? The best motor response is 6.
 The patient localises the pain. The best motor response is 5.
 The patient withdraws from pain. The best motor response if 4.
 The patient responded with abnormal flexion. The best motor response is 3.
 The patient responded with abnormal flexion. The best motor response is 2.
 The patient didn’t respond. The best motor response is 1.
2. BSL AND URINE DIPSTICK
 I would like to check the blood sugar level of the patient.
 If less than 3 mmol/L, I would like to give Intravenous 50 ml of 50% glucose.
3. EVIDENCE OF INJURY
 On inspection of the head and face, there are no trauma or evidence of injury such as racoon eyes or battle sign. I will
also check for any signs of trauma or injury all over the body of the patient.
4. SKIN BITES AND INJECTION
 There are no signs of skin bites.
 No injection sites on the arms and on the abdomen.
5. EYE MOVEMENT
 The patient is not spontaneously moving his eyes.
6. PUPILLARY RESPONSE
 The pupils are normal in size. Not dilated or constricted.
 The direct and consensual light reflexes were normal.
7. FUNDOSCOPY
 I would like to do a fundoscopic examination of the patient.
8. BREATHING
 There is no cheyne-stokes breathing, no ataxic respiration and no hypoventilation.
 No breathe odour specific for ketoacidosis, alcohol or fetor hepaticus.
9. NECK STIFFNESS
 On palpation of the neck, there’s no neck stiffness appreciated.

DIFFERENTIAL DIAGNOSES:

1. Meningitis
2. Encephalitis
3. CVA
4. Epilepsy
5. Trauma
6. Drug
7. Hypoglycemia
8. Alcohol
9. Multi-organ Failure
10. CO narcosis

INVESTIGATIONS:

1. FBE
2. Blood cultures
3. CRP
4. LFT’s
 5. UEC, RFT’s
6. Blood or urine drug screen
7. Cranial CT scan
8. Consider LP

Management:

 He will be admitted in this hospital.

 I will administer Thiamine, Oxygen, Naloxone and IV bolus of glucose.
 I will refer him to my senior or specialist
 Further management will depend on the results of the investigation.