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What makes a good doctor? One of many essential attributes is the ability to take a good history, appropriately examine, and apply sound clinical judgement to reach the correct diagnosis.
All 19 chapters in this book have the same format. Each starts with a patient’s history concerning a common complaint and asks you, the reader, to generate a differential diagnosis based upon the information supplied. This is then followed by the examination fi ndings, thus helping you refi ne the diagnostic process so that you are able to arrive at a single principal working diagnosis. The emergency management of this condition is then discussed. Our hope is that working through these cases will be enjoyable, and that you will refi ne your diagnostic skills. This man is in a coma, which is defi ned as ‘unrousable unresponsiveness’.
Using the objective clinical assessment tool, the Glasgow Coma Score (see Table 1.1), coma is defi ned as a score of 8 or less. Those patients with a score between 14 and 9 are defi ned as having altered consciousness and those with a top score of 15 are normal, alert and orientated. When considering a differential diagnosis for the cause of a patient’s unresponsiveness it is important to consider those conditions that are easily reversible fi rst. Hypoglycaemia The patient is a known diabetic. Hypoglycaemia or, less commonly, hyperglycaemia can result in altered consciousness and must be actively diagnosed and promptly treated. A simple bedside glucose test will identify abnormalities in blood glucose levels and will guide appropriate therapy. It is essential that any patient with confusion, altered consciousness, coma or focal neurological signs has their blood glucose estimated as part of the initial assessment. Neurological signs resulting from hypoglycaemia usually resolve quickly with treatment
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