Coma and consciousness alterations

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Differentiating Hypoglycemia from other Diseases that Cause Coma and Consciousness Alterations:

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
CT /MRI CSF Findings Gold standard test Neck stiffness Motor or Sensory deficit Papilledema Bulging fontanelle Cranial nerves Headache Fever Altered mental status
Hypoglycemia Serum blood glucose

HbA1c

✔ ✔ ✔ History of diabetes Palpitations, sweating, dizziness, low serum, glucose
Brain tumor[1][2] ✔ Cancer cells[3] MRI ✔ ✔ ✔ ✔ ✔ ✔ Cachexia, gradual progression of symptoms
Delirium tremens ✔ Clinical diagnosis ✔ ✔ ✔ ✔ ✔ ✔ Alcohol intake, sudden withdrawal or reduction in consumption Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus,
Subarachnoid hemorrhage[4] ✔ Xanthochromia[5] CT scan without contrast[6][7] ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Trauma/fall Confusion, dizziness, nausea, vomiting
Stroke ✔ Normal CT scan without contrast ✔ ✔ ✔ ✔ ✔ TIAs, hypertension, diabetes mellitus Speech difficulty, gait abnormality
Neurosyphilis[8][9] ✔ ↑ Leukocytes and protein CSF VDRL-specific

CSF FTA-Ab -sensitive[10]

✔ ✔ ✔ ✔ ✔ ✔ Unprotected sexual intercourse, STIs Blindness, confusion, depression,

Abnormal gait

Viral encephalitis ✔ Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose Clinical assesment ✔ ✔ ✔ ✔ ✔ ✔ ✔ Tick bite/mosquito bite/ viral prodrome for several days Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioral changes
Herpes simplex encephalitis ✔ Clinical assesment ✔ ✔ ✔ ✔ ✔ History of hypertension Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy Normal ✔ ✔ ✔ History of alcohol abuse Ophthalmoplegia, confusion
CNS abscess ✔ ↑ leukocytes >100,000/ul, ↓ glucose, ↑protein, ↑ red blood cells, and lactic acid >500mg Contrast enhanced MRI is more sensitive and specific,

Histopathological examination of brain tissue

✔ ✔ ✔ ✔ ✔ ✔ ✔ History of drug abuse, endocarditis, ↓ immune status High-grade fever, fatigue, nausea, vomiting
Drug toxicity ✔ ✔ Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder Diagnosis of exclusion ✔ ✔ ✔ ✔ ✔ Tremors, blindness, difficulty swallowing
Electrolyte disturbance Depends on the cause ✔ ✔ Confusion, seizures
Febrile convulsion Not performed in first simple febrile seizures Clinical diagnosis and EEG ✔ ✔ ✔ ✔ Family history of febrile seizures, viral illness or gastroenteritis Age > 1 month,
Subdural empyema ✔ Clinical assessment and MRI ✔ ✔ ✔ ✔ ✔ ✔ History of relapses and remissions Blurry vision, urinary incontinence, fatigue

References

  1. ↑ Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
  2. ↑ Invalid <ref> tag; no text was provided for refs named pmid3883130
  3. ↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
  4. ↑ Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
  5. ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
  6. ↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  7. ↑ DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
  8. ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
  9. ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  10. ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
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