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

> An endocrine emergency case for medical students: a 58-year-old found confused and drenched in sweat after two days of diarrhoea and vomiting. First steps, what to ask, first tests and the differential.

- Endocrinology · Intermediate · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/58-year-old-man-who-is-sweaty-and-hard-to-wake
- Work up this patient: https://www.medikarya.in/case-studies/58-year-old-man-who-is-sweaty-and-hard-to-wake

## How the patient presents

His wife found him confused and drenched in sweat this morning, and now he barely responds. He has had loose motions and vomiting for two days. She is with him and tells you what she knows.

## 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.

### Heart

- Silent myocardial infarction
- Arrhythmia

### Infection

- Sepsis
- Gastroenteritis with shock

### Metabolic

- Hypoglycaemia
- Low sodium
- Diabetic ketoacidosis or hyperosmolar state

### Toxic

- Alcohol
- Organophosphate poisoning
- Overdose

### Brain

- Stroke

## 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.

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