History

Once the patient is stable it is important to obtain as much information as possible from those who accompanied the patient to hospital or who watched the onset of coma. The circumstances in which consciousness is lost are of vital importance in helping to identify the diagnosis. Generally, coma is likely to present in one of three ways: as the predictable progression of an underlying illness; as an unpredictable event in a patient with a previously known disease; or as a totally unexpected event. Distinctions between these presentations are often achieved by the history of the circumstances in which consciousness was lost. In the first category are patients following focal brain stem infarction who deteriorate or those with known intracranial mass lesions who show similar deterioration. In the second category are patients with recognised cardiac arrhythmia or the known risk factor of sepsis from an intravenous line. In the final category it is important to determine whether there has been a previous history of seizures, trauma, febrile illness, or focal neurological disturbances. The history of a sudden collapse in the midst of a busy street or office indicates the need for different investigations from those necessary for the patient discovered at home in bed surrounded by empty bottles which previously contained sedative tablets.

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