Sweaty and hard to wake, a 58-year-old: a case to work up

Why reduced consciousness with sweating matters

A sweaty, drowsy patient may have a problem you can fix in a minute or one that needs much more, such as sepsis, poisoning or a heart attack. Check the glucose first, then work out why it happened.

What to ask in the history

• When he was last well, and how it came on
• The diarrhoea and vomiting: how much, can he keep anything down
• Diabetes, and every medicine for it; recent changes
• Kidney disease
• Alcohol
• Chest pain
• Fever
• Pesticides or other poisons
• Other medicines

Red flags

• Low conscious level
• Low glucose
• Low blood pressure, fast pulse
• Chest pain or an abnormal ECG
• Seizures
• Very little urine

What to examine

• Airway, breathing, circulation; conscious level; glucose
• Observations including temperature
• Hydration
• Pupils, sweating, secretions
• Chest and abdomen
• Neurological signs

First investigations

• Glucose at once, and repeated
• Electrolytes and kidney function
• Blood gas, lactate
• ECG, troponin
• Full blood count, CRP, cultures
• A careful list of his medicines
• CT head if the cause is not found

Differential diagnosis of reduced consciousness with sweating

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

Common mistakes

• Checking the glucose once and moving on.
• Not checking kidney function: many medicines build up when the kidneys falter.
• Forgetting that a heart attack can be silent in diabetes.