# Found unconscious at home, a 40-year-old: a case to work up

> An emergency case for medical students: a 40-year-old found unconscious by his wife. The first minutes, what to ask the witness, red flags, the first tests and the differential of coma.

- Endocrinology · Intermediate · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/40-year-old-man-found-unconscious-at-home
- Work up this patient: https://www.medikarya.in/case-studies/40-year-old-man-found-unconscious-at-home

## How the patient presents

A 40-year-old man's wife came home from work in the evening and found him unconscious. He has had a painful foot for a few weeks. She is with him and tells you what she knows.

## Why unconsciousness of unknown cause matters

The unconscious patient needs several things at once: protect the airway, check the glucose, and look for clues. Many causes are metabolic, toxic or infective, and reversible if found quickly.

## What to ask in the history

- When he was last seen well, and how he was found
- Diabetes or other illness; medicines, missed doses
- Vomiting, thirst, passing a lot of urine
- The painful foot: how long, any wound, swelling
- Alcohol, drugs, access to poisons
- Seizures, headache, injury

## Red flags

- Airway at risk
- Abnormal breathing pattern
- Very high or very low glucose
- Shock
- Fever
- Unequal pupils or signs on one side

## What to examine

- Airway, breathing, circulation; conscious level; glucose
- Observations
- Breath: smell, depth and pattern
- Pupils, neck stiffness, injuries
- Skin and feet: wounds, infection
- Hydration
- Neurological signs

## First investigations

- Capillary glucose and ketones
- Blood gas: pH, bicarbonate, anion gap, lactate
- Electrolytes, kidney function, osmolality
- Full blood count, CRP, blood cultures
- Urine
- ECG
- Toxicology
- CT head if no metabolic cause is found or there are focal signs
- X-ray of the foot

## Differential diagnosis of unconsciousness of unknown cause

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Brain

- Stroke
- Bleeding
- Seizure
- Head injury

### Infection

- Sepsis
- Meningitis or encephalitis

### Metabolic

- Diabetic ketoacidosis
- Hyperosmolar state
- Hypoglycaemia
- Sodium disorders
- Kidney or liver failure

### Toxic

- Alcohol
- Overdose
- Poisoning

## Common mistakes

- Not checking the glucose.
- Correcting a very high glucose too fast, or forgetting the potassium.
- Treating the numbers and not finding what set it off.

---

A study guide for medical students, not medical advice. Follow your institution's protocols in practice.