EVIDENCE OF PUNCTURE WOUNDS

vconsciousness in hypertensive patient favours diagnosis of intracerebral hemorrhage 4 History of severe psychological disturbance - raises possibility of self-administered drug intoxication. History of alcoholic intake. 6. History of head injury - (i) On admission - Diffuse shearing injury and/or intracranial hematoma. (ii) Previous head injury (e.g. 6 weeks) - Chronic subdural hematoma. 7. History of bleeding diathesis - Non-traumatic intracerebral hemorrhage is usually associated with systemic hypertension, but may occur in patients with bleeding diathesis. 8. Recent symptoms suggestive of a tumour -e.g., headache, personality change or insidious hemiparesis. 9. Symptoms of cerebellar hemorrhage -Headache, vertigo and vomiting, with unilateral cerebellar ataxia, would suggest occurrence of hemorrhage into one cerebellar hemisphere. 10. Past history - Of diabetes mellitus, epilepsy (post-ictal state), renal disease, cardiac or respiratory failure or of hypertension or malignancy (intracranial metastasis) Previous overdose attempts due to depressive illness. B. General examination - 1. GENERAL APPEARANCE - Flushed face in alcoholic, pale yellow in uremia, cherry red in carbon monoxide poisoning. Cold clammy skin suggests hyperinsulinism or morphine poisoning, pigmentation of skin and buccal mucosa in Addison's disease; petechiae in skin suggestive of cerebral embolism. Fever - usually indicates a systemic infection, meningitis, cerebral malaria, encephalitis or cerebral abscess. 2. ODOUR - of alcohol, acetone in diabetes, ammoniacal in uremia, and of drug like cyanide. Foetor hepaticus in hepatic coma. Pungent odour in organo-phosphorus poisoning. 3. HEAD - Depressed fracture of skull may be palpable. 4. EARS - Blood may suggest basal fracture Middle ear infection or tenderness and swelling over mastoid may indicate an intracranial abscess. EYES - (a) Jaundice in liver failure. (b) Soft eyeballs in diabetic acidosis. (c) Resistance to opening of eyes and rolling up of eye balls in hysterical coma. 6. HYPOTHERMIA - following exposure to low temperatures, intoxication with alcohol or hypnotics, profound myxoedema or peripheral circulatory failure. 7. TACHY or BRADYARRHYTHMIAS, or evidence of valvular heart disease or peripheral emboli suggest cardiogenic cause. Bruits over carotids suggest cerebravascular disease. 8. HYPOTENSION - Possibility of shock, myocardial infarction or septicemia or Addison's disease. 9. RESPIRATION - Slow, shallow breathing suggests drug intoxication. Deep and rapid respirations suggest pneumonia or metabolic acidosis. Periodic respiration suggests cardiac or brainstem lesion. 10. ENLARGEMENT OF AN ABDOMINAL ORGAN - might indicate portal hypertension, polycystic kidneys and an associated SAH. 11. PURPURA - suggests a bleeding diathesis, and bruising around the head possible trauma or fracture at base of skull. 12. RASH - may indicate an infective or inflammatory disease. 13. EVIDENCE OF PUNCTURE WOUNDS - may identify a diabetic patient or a drug user. C. Neurological examination 1. Observation and assessment of reflex responses - (a) Position, posture and spontaneous movements of the patient should be noted (b) Examination of skull and spine, and testing for neck stiffness and Kernig's sign identify meningeal irritation. 2. Level of consciousness - Most useful is the Glasgow Coma