Decreased LOC
Age: years old
Gender:
HISTORY:
Presents with a decreased level of consciousness that began ago
Onset was
Last known normal ago
Witnessed by , and described as
Associated symptoms:
, , , ,
confusion
aphasia
weakness
seizure
, up to °, over
, episodes , ,
, , , ,
trauma
depression
, , a plan, intent to act
Contributing factors:
no history of: , , , ,
no use of: , , , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head: , scalp
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Extremities: , , cap refill sec, pulses , ,
Musculoskeletal: joints ,
Neurologic:
- Mental status: , oriented to , speech
- Cranial nerves:
- Strength: except for on ,
- Sensation: to on
- Reflexes: except for on ,
- Cerebellar function: , finger-nose, rapid alternating movements, heel-shin, Romberg , Dix-Hallpike
- Gait: , tandem gait, heel walk and toe walk
ASSESSMENT:
DDx: syncope, seizure, stroke, hypoglycemia, intoxication, infection (e.g., meningitis, encephalitis, sepsis), head trauma, subdural hematoma, intracerebral hemorrhage, brain tumor, hydrocephalus, postictal state, metabolic encephalopathy, hypoxia, hypercapnia, electrolyte imbalance, hepatic encephalopathy, uremic encephalopathy, thyroid storm, myxedema coma, adrenal crisis, heat stroke, hypothermia, drug overdose, alcohol withdrawal, sedative-hypnotic withdrawal, psychiatric conditions (e.g., catatonia), dementia with acute decline, delirium, carbon monoxide poisoning, anemia, cardiac arrest, shock, status epilepticus
PLAN:
Investigations:
- Blood work: , , , , , , , , , , , ,
- Urinalysis
- Chest X-ray
- ECG
- CT scan of the head
- MRI of the brain
- EEG
- Lumbar puncture
Treatments:
-
-
-
-
-
-
-
-
Further care:
- Continuous monitoring of vital signs
- ICU admission
- Referral to neurology
- Referral to toxicology
- Referral to critical care
- Follow-up in
- Return if level of consciousness decreases further or if new symptoms such as seizures, focal neurological deficits, or respiratory distress develop
HISTORY: EXAM: Neurologic: ASSESSMENT: PLAN: