Файл: PLUM AND POSNER S DIAGNOSIS OF STUPOR AND COM-1.pdf

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OVERVIEW

HISTORY

GENERAL PHYSICAL EXAMINATION

LEVEL OF CONSCIOUSNESS

ABC: AIRWAY, BREATHING,

CIRCULATION

Circulation

Respiration

PUPILLARY RESPONSES

Examine the Pupils and Their Responses

Pathophysiology of Pupillary Responses:

Peripheral Anatomy of the Pupillomotor

System

Pharmacology of the Peripheral

Pupillomotor System

Localizing Value of Abnormal Pupillary

Responses in Patients in Coma

Metabolic and Pharmacologic Causes

of Abnormal Pupillary Response

OCULOMOTOR RESPONSES

Functional Anatomy of the Peripheral

Oculomotor System

OVERVIEW

Coma, indeed any alteration of consciousness, is a medical emergency. The physician encountering such a patient must begin examination

Functional Anatomy of the Central

Oculomotor System

The Ocular Motor Examination

Interpretation of Abnormal

Ocular Movements

MOTOR RESPONSES

Motor Tone

Motor Reflexes

Motor Responses

FALSE LOCALIZING SIGNS IN PATIENTS

WITH METABOLIC COMA

Respiratory Responses

Pupillary Responses

Ocular Motor Responses

Motor Responses

MAJOR LABORATORY DIAGNOSTIC AIDS

Blood and Urine Testing

Computed Tomography Imaging

and Angiography

Magnetic Resonance Imaging

and Angiography

Magnetic Resonance Spectroscopy

Neurosonography

Lumbar Puncture

Electroencephalography and

Evoked Potentials

and treatment simultaneously. The examination must be thorough, but brief. The examination begins by informally assessing the patient’s level of consciousness. First, the physician addresses the patient verbally. If the patient does

not respond to the physician’s voice, the physician may speak more loudly or shake the patient. When this fails to produce a response, the physician begins a more formal coma evaluation.

The examiner must systematically assess the arousal pathways. To determine if there is a structural lesion involving those pathways, it is necessary also to examine the function of brainstem sensory and motor pathways that are adjacent to the arousal system. In particular, because the oculomotor circuitry enfolds and surrounds most of the arousal system, this part of the examination is particularly informative. Fortunately, the examination of the comatose patient can usually be accomplished very quickly because the patient has such a limited range of responses.However,theexaminermustbecome conversant with the meaning of the signs elicited in that examination, so that decisions that may save the patient’s life can then be made quickly and accurately.

The evaluation of the patient with a reduced level of consciousness, like that of any patient, requires a history (to the extent possible), physical examination, and laboratory evaluation. These are considered, in turn, in this chapter. However, as soon as it is determined that a patient has a depressed level of consciousness, the next step is to ensure that the patient’s brain is receiving adequate blood and oxygen.

The emergency treatment of the comatose patient is detailed in Chapter 7. The physiology and pathophysiology of the cerebral circulation and of respiration are considered in the paragraphs below.

HISTORY

In patients with nervous system dysfunction, the history is the most important part of the examination (Table 2–1). Of course, patients with coma or diminished states of consciousness by definition are not able to give a history. Thus, the history must be obtained if possible from relatives, friends, or the individuals, usually the emergency medical personnel, who brought the patient to the hospital.

The onset of coma is often important. In a previously healthy, young patient, the sudden onset of coma may be due to drug poisoning, subarachnoid hemorrhage, or head trauma; in the elderly, sudden coma is more likely caused

Table 2–1 Examination of the

Comatose Patient

History ( from Relatives, Friends, or Attendants)

Onset of coma (abrupt, gradual)

Recent complaints (e.g., headache, depression, focal weakness, vertigo)

Recent injury

Previous medical illnesses (e.g., diabetes, renal failure, heart disease)

Previous psychiatric history

Access to drugs (sedatives, psychotropic drugs)

General Physical Examination

Vital signs Evidence of trauma

Evidence of acute or chronic systemic illness Evidence of drug ingestion (needle marks,

alcohol on breath)

Nuchal rigidity (assuming that cervical trauma has been excluded)

Neurologic Examination

Verbal responses Eye opening Optic fundi Pupillary reactions

Spontaneous eye movements Oculocephalic responses (assuming cervical

trauma has been excluded) Oculovestibular responses Corneal responses Respiratory pattern

Motor responses Deep tendon reflexes Skeletal muscle tone

by cerebral hemorrhage or infarction. Most patients with lesions compressing the brain either have a clear history of trauma (e.g., epidural hematoma; see Chapter 4) or a more gradual rather than abrupt impairment of consciousness. Gradual onset is also true of most patients with metabolic disorders (see Chapter 5).

The examiner should inquire about previous medical symptoms or illnesses or any recent trauma. A history of headache of recent onset points to a compressive lesion, whereas the history of depression or psychiatric disease may suggest drug intoxication. Patients with known diabetes, renal failure, heart disease, or other chronic medical illness are more likely to be suffering from metabolic disorders or perhaps brainstem infarction. A history of premonitory signs, including focal weakness such as dragging