This is a hot case where the candidate is launched at a comatose patient, with the objective of discovering the cause of that unconsciousness.
For the candidate, the key is to distinguish between the different flavours of coma. The chapter on the approach to the examination of an unconscious patient contains a long comprehensive list of differentials, and digresses extensively on the examination. For the time-poor candidate, the LITFL entry on this topic is much easier to use for revision.
An abbreviated version of that huge list of differentials would resemble the following:
With focal signsStroke Haemorrhage Abscess Trauma Tumour |
Without focal signsDrugs Metabolic problem: one of the many encephalopathies (see COATPEGS):
Diffuse cerebral vascular issues Brainstem problem (eg. stroke) Encephalitis Seizures Vasculitis |
With meningismVascular causes:
Infectious causes:
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One can get far using the LITFL TOMES/COATPEGS mnemonics. TOMES stands for "toxins, organ failure, metabolic, endocrine, seizures" and COATPEGS stands for "oxygen, carbon dioxide, ammonia, temperature, pH, electrolytes, glucose and serum osmolality". Sure, some of the causes of non-focal unconsciousness are missing, but if you add them all, you end up with "COMATOSE GREAT APE"
COMATOSE
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GREAT
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APE
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A suggestion made by an ex-examiner is as follows:
Number of previous hot cases in this topic: 16
Unspecified hospital in Adelaide |
73-year-old male day 1 ICU admitted following a MET call for decreased conscious state that required intubation. He had been admitted with shortness of breath, fever, headache and collapse and found to have meningococcal meningitis. Background included ischaemic heart disease on dual anti-platelet therapy and COPD. Findings on examination included ecchymoses, bronchial breathing left lung, right upgoing plantar and the absence of meningism. Candidates were directed to determine the likely cause for the decrease in conscious state. Discussion points included interpretation of the CSF results, management of meningitis and the role of steroids. |
Unspecified hospital in Adelaide |
54-year-old female, day 5 ICU, admitted with massive haematemesis from oesophageal varices on a background of Child’s B cirrhosis secondary to auto-immune hepatitis. Other co-morbidities included biventricular failure, atrial fibrillation, hypothyroid disease and polycythaemia. Findings on examination included generalised oedema, bilateral crackles on auscultation with decreased breath sounds at the bases, distended abdomen and neurological signs with brisk reflexes and ankle clonus. Candidates were told that she had presented with upper GI bleeding that had been treated and were directed to examine her focussing on the neurological system and provide a differential diagnosis for her current clinical status. Discussion points included interpretation of biochemistry, causes of encephalopathy and management of bleeding oesophageal varices. |
Unspecified hospital in Melbourne |
24 - year - old male with a history of intravenous drug use and mitral valve endocarditis, which resulted in an embolic str oke. The patient subsequently had surgery for a mitral valve replacement from which he was recovering. Candidates were directed to perform a neurological examination and a relevant general examination. |
Unspecified hospital in Melbourne |
44 - year - old female with acute liver failure and hypox ia on a background of alcohol excess and heavy smoking. Transferred from a peripheral hospital and intubated on arrival for hypoxia and delirium . Candidates were directed to identify and discuss active issues and make a plan for the following week. |
Unspecified hospital in Sydney |
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Unspecified hospital in Sydney |
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Unspecified hospital in Sydney |
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Royal Brisbane and Women’s Hospital |
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Royal Brisbane and Women’s Hospital |
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Westmead Hospital |
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Queen Elizabeth Hospital |
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Royal Prince Alfred Hospital |
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Royal North Shore Hospital |
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Westmead Hospital |
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Royal Brisbane Hospital |
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Unspecified hospital |
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