Altered Conscious State
Dr Alex Handrinos
Case Study
A 26 yo female is brought to the ED by ambulance with an altered conscious state. She was found on the streets of Melbourne wandering around quite confused before she was seen to lie down on the floor in an alleyway and lose consciousness.
Her vital signs are HR 95, BP 110/80, RR 14, SpO2 98% RA, Temperature 37.0. BSL 6.8
Once you have answered the below questions, click on them to reveal model answers.
1) What are some differential diagnoses?
There are lots of possibilities here. Remember to think about different systems and potentially life threatening causes.
In this patient I would consider:
- Intracranial: traumatic bleed, SAH, encephalitis
- Toxicological: alcohol intoxication, recreational drug use, suicide attempt with overdose
- Metabolic: wide range of possibilities
Don't forget: What is most common? And what is life-threatening and can't be missed?
2) How would you examine this patient? What are you looking for?
- Check the vital signs
- Determine the level of consciousness. Is this patient alert, responsive to voice, responsive to pain or unresponsive. (AVPU). Alternatively, calculate a GCS
- Examine for any signs of trauma to her head.
- Look at the pupils
- Assess the limbs for spontaneous movements, tone, clonus, reflexes.
- Looks for signs of drug use. Alcohol on the breath? IV track marks? White powder in the nostrils?
- General physical exam based upon your history and list of differential diagnoses
If the patient is not responding to voice or has abnormal vital signs, get senior help urgently.
3) What investigations might you consider in this patient?
- Always check the glucose (even if done pre-hospital)
- Ethanol level
- CT Brain? Discuss with seniors.
- Other investigations based on your differential diagnoses