II. Background: Key goal of Coma Exam is distinguish cause

  1. Toxic or metabolic cause
  2. Structural cause

IV. Exam: General

  1. Breath (also see Toxin Induced Odors)
    1. Alcohol
    2. Fruity breath (Diabetes Mellitus)
    3. Almonds (Cyanide toxicity)
    4. Insecticides (Organophosphate Toxicity)
  2. Head Trauma signs
    1. Hemotympanum
    2. Cephalohematoma
    3. CSF leakage from nares or ear canal
  3. Neck
    1. Meningismus
    2. Thyromegaly
  4. Cardiopulmonary exam
    1. Pulmonary Rales or Wheezes
    2. Chest Scars
    3. Cardiac Murmurs
    4. Irregular rhythm (Atrial Fibrillation)
  5. Abdomen
    1. Bowel sounds
    2. Ascites or Hepatomegaly (Hepatic Encephalopathy)
    3. Abdominal Aortic Aneurysm
  6. Skin
    1. Jaundice
    2. Needle Tracks (Intravenous Drug Abuse)
    3. Petechiae
    4. Skin Temperature
    5. Hydration

V. Exam: Neurologic Observation

  1. Autisms (Involuntary protective-type acts)
    1. Yawning
    2. Hiccups
    3. Sneezing
    4. Swallowing
  2. Respiratory patterns

VI. Exam: Neurologic General

  1. Mental Status Exam
  2. Eye Neurologic Exam
  3. Oculocephalic Reflex (Doll's Eyes)
  4. Oculovestibular Testing (Cold Calorics)
  5. Motor Testing
    1. Observe at rest
      1. Spontaneous movements
      2. Posturing
    2. Purposeful movement
      1. Indicates intact Brainstem
      2. Indicates intact cortex
    3. Response to painful stimuli
      1. Abduction or adduction
      2. Posturing
        1. Decorticate Posturing
        2. Decerebrate Posturing
      3. Triple flexion response (spinal reflex)
      4. Asymmetric response
      5. Flaccid paralysis

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