Approach to A Patient Presenting With Unconciousness

A patient with unconsciousness is usually brought o the emergency department and is categorized as having a GCS of less than 8.
There may be many causes that can lead to unconsciousness. A list of these are given below:

Causes;

1. Trauma:
   
- Head injury:

• Diffuse axonal injury.
• Extradural hemorrhage. 
• Subdural hemorrhage. 

2. Metabolic causes: 

• Hypothermia
• Hypoglycemia
• Hyperglycemia
• Hypernatremia
• Diabetic ketoacidosis

3. Organ failure: 

• Cardiac/circulatory failure
• Respiratory failure
• Liver failure leading to encephalopathy.
• Renal failure (uremic coma)
• Hypothyroidism

4. Vascular causes: 

• Stroke.
• Subarachnoid hemorrhage. 

5. Infections:

• Meningitis
• Encephalitis
• Cerebral malaria.

6. Toxins or Drug Induced: 

• Alcohol
• Overdose of opiates tricyclics, benzodiazepines
• Carbon monooxide poisoining

7. Neurologic Causes: 

• Brain tumor
• Brain abscess
• Epilepsy

Clinical History: The history of an unconscious patient is usually obtained from the ambulance crew, relatives, friends or witnesses. other sources of information are previous hospital notes and records kept by general practitioners and tablets or prescriptions found at the patient's premises.

Regarding Normal Sleep Biology

Which of the following statements about normal sleep biology is FALSE?

A. Parasomnias include sleep walking, sleep talking and night terrors.

B. There are no significant age related changes in sleep duration and sleep patterns between infancy, early childhood, young adulthood and old age.

C. Sleep can be segregated into 5 stages although the REM stage is so distinctive that sleep is often separated in to REM and non-REM sleep.

D. Duration of sleep and walking is one of the most prevalent health disorders in persons in the US and is a major public health concern accounting, for example, for many traffic accidents.


The correct answer is:

A 48 Year Old Patient With Breathlessness And Ankle Swelling

You are seeing a 48 year old patient in your clinic who has a 3 month history of progressive exertional dyspnoea, fatigue and peripheral edema. He has been generally fit and without prior medical history. He mentions his father died in his forties due to 'large heart'. He is not taking any medications and you start furosemide 40 mg once daily.
Regarding the case answer the following questions:

Q 1. What further questions you should ask in history? 

Answer: Ask about:
• Chest pain: if present, does this sound like ischemic cardiac pain or like pleurisy?
• Cough/sputum: has it been present and has there been haemoptysis?
• Wheeze: note that this is not synonymous with airway disease. It may occur in pulmonary oedema when it is known as ‘cardiac asthma’.
• Recurrent asthma/bronchitis or any other respiratory problem.
• Smoking, which is obviously a substantial risk factor for both chronic airway disease and ischaemic heart disease.
• Alcohol intake, which is a risk factor for cardiomyopathy. Ask: ‘How much alcohol do you drink now? Have you ever been a heavy drinker in the past?’
• Previous BP measurements: untreated hypertension can lead to left ventricular failure.
• Previous cardiac surgery might be suggestive of impaired left ventricular function or constrictive pericarditis

Q 2 . List The Differential Diagnosis for a patient with breathlessness and ankle swelling? 

Answer: Differential Diagnosis

Gastroesophageal Reflux Disease

A 35 year old man presents in your clinic complaining of substernal chest pain and a metallic taste in mouth. He has been having this pain for the past few months and usually starts when he take heavy oily meals. You suspect GERD (gastroesophageal reflux disease).
Answer the following questions.

Q 1. What are the alarming signs and when should one perform endoscopy in a patient with suspected GERD?

Answer: The following symptoms should be considered serious and an endoscopy should be performed:

• Weight loss
• Anemia
• Blood in stool
• Dysphagia

Etiologies Of Fever Of Unknown Origin.

Fever Of Unknown Origin( FUO ) in adults is defined as fever greater than 38.3◦C of at least 3 weeks duration with no obvious cause despite extensive evaluation.

Infections are the most common source of FUO in children and young adults. The most common infections include TB and abscesses. In older adults, collagen-vascular diseases, such as giant cell arteritis and rheumatoid arthritis, are more likely sources of FUO.

A List Of possible etiologies of FUO is given below:

1. Infections

• Tuberculosis
• Lyme disease
• HIV
• Endocarditis
• Dental abscess
• Abdominal/pelvic abscess
• CMV
• Epstein–Barr virus

2. Malignancies

• Metastatic cancer
• Lymphoma
• Leukemias
• Renal cell carcinoma

(The most common malignancies to present with FUO are lymphoma, leukemia, renal cell carcinoma, and hepatoma.)

Edema - Differential Diagnosis

Edema is the accumulation of excessive fluid in the subcutaneous tissue. When edema results from lymphatic stasis, the term lymphoedema is used.

Causes: 

Generalized Edema :

1. Increased plasma hydrostatic pressure: 

• Congestive heart failure
• Vasodilatory drugs: e.g nifedipine

2. Decreased plasma oncotic pressure: 

• Liver disease
• Renal disease e.g Nephrotic syndrome
• Malnutrition
• Malabsorption

3. Increased capillary permeability:

Obstructive Sleep Apnea Syndrome

A 40 year old obese man come to see his physician because he has been suffering from fatigue and day time sleepiness for the previous 2 months. He has been described as a loud snorer and lately he has loss interest in sex. His performance at work is getting poor and he usually suffers from morning headaches.

What is the Differential Diagnosis?

• Obstructive sleep apnea syndrome
• Atypical depression
• Hypothyroidism
• Insufficient sleep
• Obesity hypoventilation syndrome ( Pickwickian syndrome)
• Nacrolepsy.

What are the complications of Obstructive sleep apnea syndrome ?

• Pulmonary hypertension that can lead to Cor pulmonale
• Type II respiratory failure.

What investigations are helpful in the diagnosis of Obstructive sleep apnea?

1. Simple studies e.g pulse oximetry and video recordings are usually all that is needed for the diagnosis. 

Approach To A Patient Presenting With Chest Pain

Medical students during their posting in medical ward are being taught how to approach a patient who presents with a complain of chest pain.
Chest pain is a very common presenting system of a variety of medical conditions. These may be trivial or life threatening.
A brief summary is given below on how to approach to a case of Chest Pain

Causes Of Chest Pain: 

1. Cardiovascular Causes: 

• Angina
• Myocardial Infarction
• Acute aortic dissection
• Pericarditis

2. Gastrointestinal Causes:

• Reflux esophagitis
• Esophageal spasm
• Peptic ulcer disease

3. Pulmonary Causes:

• Pneumonia
• Pulmonary embolism
• Pneumothorax

4. Musculoskeletal Causes:

• Chest wall injuries
• Costochondritis
• Metastasis to ribs 
• Herpes zoster

5. Emotional

• Depression

History And Physical Examination: As for any case initial history and examination are an important aspect in reaching a diagnosis for a patient who presents with chest pain. 

1. Character of Pain: Ask about the nature and character of pain. 

A Case Of Post traumatic Headache

A 45 year old gentleman presents with a history of headache for 3 weeks. His past history reveals a migraine headache since 20 years and a fall 3 weeks ago.

1. What further questions would you explore in the history?
2. List 3 most likely differentials?
3. Outline your management plan?

Question solved:

Differential Diagnosis Of Abdominal Pain

Here is a list for different causes for Abdominal Pain:

Gastrointestinal Causes:

1. Gastroduodenal:

• Peptic Ulcer
• Gastritis
• Gastric Volvulus
• Malignancy

2. Intestinal :

• Appendicitis
• Obstruction
• Diverticulitis
• Gastroenteritis
• Inflammatory bowel disease
• Mesenteric adenitis
• Strangulated hernia
• Intussusception
• Volvulus
• Tuberculosis

3. Hepatobiliary:

• Acute cholecystitis
• Chronic cholecystitis
• Cholangitis
• Hepatitis

4. Pancreatic:

• Acute pancreatits
• Cronic pancreatitis
• Malignancy

5. Splenic:

• Infarction
• Spontaneous rupture

Urinary causes: