Approach to the patient in Coma: History Taking

by Munirah Mansor

Approach to the patient in Coma:

History Taking
In many cases the cause of the coma is immediately evident (e.g. trauma, cardiac arrest, or known drug ingestion).
But in the remainder, history is crucial.

Obtain a collateral history from family/friends, witnesses or ambulance crew.

Approach to the patient in Coma:

History Taking
History of Presenting Illness Past Medical / Surgical History Drug History Family History Social/Personal History

Approach to the patient in Coma:

History Taking
Key areas:
1.The circumstances & rapidity with which the neurologic symptoms developed 2.The antecedent symptoms 3.Drug/Social History 4.Past Medical History

Approach to the patient in Coma: History

1) The circumstances & rapidity with which the neurologic symptoms developed
Has it ever happened before?
If so, how many times? Did the person behave the same way on previous episodes?

Establish the circumstances in which the coma occurred.

Is this the predictable progression of an existing disease?
(e.g. brainstem infarction, intracranial mass lesions, subarachnoid haemorrhage)

Or is this an unpredictable event associated with a preexisting disease? (e.g. cardiac arrhythmia, systemic sepsis)

Approach to the patient in Coma: History

1) The circumstances & rapidity with which the neurologic symptoms developed Time pattern: evolution of the comatose state
Sudden onset - vascular origin? Gradual progression over a few hours metabolic derangement? Drug overdose? Gradual evolution over several days suggests infection, tumor, abscess, subdural hematoma, or a metabolic process. (less likely to be related to ischemia or drug overdose)

Approach to the patient in Coma: History

2) The antecedent symptoms

Recent trauma? Symptoms of hypoglycemia? Headache (subarachnoid or intracerebral bleed, CNS infection?) Seizures (metabolic derangement?) Fever (CNS or systemic infection?) Chest pain (aortic dissection or myocardial infarction?) Shortness of breath (hypoxia?)

Approach to the patient in Coma: History

2) The antecedent symptoms

Stiff neck (meningoencephalitis) Vertigo (brain stem vascular accident) Nausea and vomiting - common in poisoning. Descriptions of falling to one side, dysarthria or aphasia, diploplia etc - may help localise structural lesion.

Approach to the patient in Coma: History

3) Drug/Social History
Medical drug history
Insulin, OHA , Antipsychotics, Sedatives, Steroids, Anti coagulants, Diuretics

Habitual use of alcohol or illicit drugs? Any recent travel?

Approach to the patient in Coma: History

4) Past Medical History Known epilepsy or seizure disorder? Diabetes Mellitus? Hypertension? Liver disease? Renal disease / failure? Psychiatric history
H/o depression? Past suicide attempts?

Any diseases related to immunosuppression?