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Major Differential Diagnosis of Altered Consciousness (groups & examples)
Metabolic Diseases;Hypoglycemia,DKA, NonketoticHyperglycemic coma, CKD (uremia) Hepatic encephalopathy, CO2 narcosis ,Wilson’s Disease,Wernicke’sencephalopathyInfections; cerebral malaria, acutepyogenicmeningitis, encephalitis (viral).Vacularaccidents;haemorrhagic/ischemicstroke,SAH,chronicsubdural/ ExtraduralhaematomaDrugs toxicity/overdosage; sedatives,drugs used by pocketpickers,opium,alcohol .Tumoursi.e. ICSOLHead injury/ Trauma
Types of HE
Type A (=acute)describes hepatic encephalopathy associated withacute liver failuretypically associated withcerebraloedemaType B (=bypass)is caused by portal-systemic shunting without associated intrinsic liver diseaseType C (=cirrhosis) occurs in patients withcirrhosis-episodic,persistentandminimalencephalopathy
Assessing the Severity of HE
Two types of scoring system is available which can be applied for the assessment of the severity of the condition;West Haven CriteriaGlassgowComa scale
Grading of HepaticEncephlopathy(West Haven Criteria)
Grade 0.Lack of detectable changes in personality or behavior.Asterixisabsent.Grade 1.Trivial lack of awareness. Shortened attention span. Impaired addition or subtraction.Hypersomnia, insomnia, or inversion of sleep pattern. Euphoria or depression.Asterixiscan be detected.Grade 2.Lethargy or apathy. Disorientation. Inappropriate behavior. Slurred speech. Obviousasterixis.Grade 3.Gross disorientation. Bizarre behavior.Semistuporto stupor.Asterixisgenerally absent.Grade 4.Coma.
Level of consciousness inGlassgowComa Scale;to obtain the score,ocular,verbaland motor responses are summed up. The best is 15 the poorest 3, anything >12 is severe encephalopathy
Clinical Examination
Salam/ GreetingIntroductionConsentIf the patient is conscious and able tocommunicate,otherwiseask the assistance of the attendant of the patient.
Evoluationof the High Mental Functions
Speech; the disturbance of speech is the earliest sign of hepaticencephlopathy. Going through the greetings and consent , it might has been assessed to a sufficient degree,egslurred,dysarthricetcetcSleep; reversal of the sleep pattern is again an earlier sign of the onset of HE. Ascertain it by asking the sleep pattern. Patients are sleepy at the day while awake at night, if under the effect of encephalopathy.
Evoluationof the High Mental Functions (cont…)
Orientation; Three parameters should be assessed.Time; orientation to the time is 1stto be disturbed. Patient lose recognition of timePlace/spacePerson
Evoluationof the High Mental Functions (cont…)
Memory; 3 types of memory should be assessed’PastRecentRecallArithematics/mathematics; simple mathematical questions are asked from the patientaccrdingto his educational statuseg100-7= ? And so on
Evoluationof the High Mental Functions (cont…)
Figure tracking/ tracing; figures 1-30 are written in haphazard way on a piece of paper, and the patient is asked to join them serially. A normal individual would take 15-30 seconds to join them, however a pt. under the effect of HE would take longer. This test can not beexcecisedin anillitratepatient.Constructionalapraxia; make simple shapes on a piece of paper like a circle, triangular, star in front of the patient and ask him/her to copy. A patient who is having problem inmentationwould make deformed shapes .
Examination of the eyes;Jaundice,anemia,KFrings,Size and reaction of the pupils (constricted pupils in opium toxicity andpontinehaemorrhage.Fundoscopy;papilloedemain ICSOL, High intracranial pressure, hypertensive encephalopathy, diabetic retinopathy
Examination of the mouthPeculiar smell offoetorhepaticus, diabeticketoacidosis,organophosphatepoisoning. There is no need to take the nose near the mouth of the patient, it could be appreciated as such ,if any.Hyperpigmentationof thebuccalmucosa inaddisson’sdisease comaFace ,neck andchest;spidernevi ,gynaecomastia,axillaryhair
Examination of Hands; clubbing,lukonychia, palmererythema,Duputren’scontracture, bruises,petechiae, spider neviFlapping tremors; ask the patient to outstretch the hands and arms by hyper-extending the fingers,wrists,elbowsand shoulders if possible. The flapping tremors would be observed if patient has grade II or grade III encephalopathy, It may also be called Bird’s wing movement or Traffic policesign.Itis usually not there in grade I and can not be elicited in grade IV encephalopathy.
Examination of the abdomen;CaputmedusaeAscites; shape, umbilicus, shifting dullness, fluid thrill.SplenomegalyLiver ,smallshrunkened/ EnlargedegHCC, liver spanHernialorifices,pubichair, testicular atrophy ( males)
Examination of the feet and legs; pittingoedema,bruises,petechiae
Quick neurological assessment
Muscle tonePowerReflexesPlantar reflex . It is bilaterally up in metabolic comas usually, but in case of focalneurogicaldisturbance it may be unilaterally up going on the affected side if due to upper MotorNeuronelesion.
Finishing the examination
Recover and reposition the patient to the initial comfortable position. While doing so, try to recapitulate the positive and relevant negative findings in your mind and prepare for the 1stquestion of examiner which usually sounds like “OK, beta! What do you think? What did you find?Always thank the patient and give a good wish to the patient (e.gAllah dekhaka) even if you are really in hurry.Face to the examiner and look him/her in eyes, in a confident way.
Mechanism of Hepatic Flapping Tremor
The patient should be able to percieve tbe command to outstretch the hands and maintain it.The sensory cortexrelaysthecommandto motorcortex. Then the motor cortex commands the effector organs to obey the command to outstretch the hands and cerebellum is directed to maintain theoutstretchedhands.As the relay syatem between thecerebellumandcerebrumis under the toxiceffectofneurotoxinsthecerebellumfails tomaintainthecoordinationand there is afall , the repetitionofthis process results in the phenomenon calledFlappingTremors.





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