Diabetic Coma: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps.

In principle, an emergency physical examination must first be performed in conscious comatose individuals:

Glasgow Coma Scale (GCS) – scale for estimating impaired consciousness.

Criterion Score
Eye opening spontaneous 4
on request 3
on pain stimulus 2
no reaction 1
Verbal communication conversational, oriented 5
conversational, disoriented (confused) 4
incoherent words 3
unintelligible sounds 2
no verbal reaction 1
Motor response Follows prompts 6
Targeted pain defense 5
untargeted pain defense 4
on pain stimulus flexion synergisms 3
on pain stimulus stretching synergisms 2
No response to pain stimulus 1

Assessment

  • Points are awarded for each category separately and then added together. The maximum score is 15, the minimum 3 points.
  • If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
  • With a GCS ≤ 8, securing the airway by endotracheal intubation (insertion of a tube (hollow probe) through the mouth or nose between the vocal folds of the larynx into the trachea) must be considered.

Subsequently, takes place:

  • General physical examination – including blood pressure, pulse, body weight, height; furthermore:
    • Inspection (viewing) of skin and mucous membranes; smelling breath [acetone odor/ketone bodies].
    • Auscultation (listening) of the heart.
    • Auscultation of the lungs
    • Palpation (palpation) of the abdomen (abdomen) (pressure pain?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, kidney bearing knocking pain?) [pseudoperitonitis diabetica – condition of most severe abdominal pain in derailed diabetes mellitus with very high blood glucose values]
  • Neurological examination – including checking reflexes and cranial nerve function [due todifferential diagnoses:
    • Apoplexy (stroke)
    • Basilar artery thrombosisocclusion of a basilar artery of the brainstem associated with severe neurologic damage.
    • Chronic subdural hematoma (cSDH) – hemorrhage between layers of the meninges that can lead to various neurological symptoms.
    • Coma vigile (akinetic mutism) – muteness with general inhibition of motor functions, which is mainly conditioned in psychiatric diseases or injuries/tumors of the brain.
    • Epilepsy
    • Increased intracranial pressure
    • Brain abscess – encapsulated collection of pus in the brain.
    • Brain mass hemorrhage
    • Cerebral sinus thrombosisocclusion of a venous cerebral blood duct.
    • Brainstem hemorrhage
    • Brainstem infarction
    • Meningoencephalitis – combined inflammation of the brain (encephalitis) and meninges (meningitis).
    • Subarachnoid hemorrhage (SAB) – bleeding between the spinal meninges and the surface of the brain; in 75-80% of cases, the cause is an aneurysm (bulging of an artery)]

Square brackets [ ] indicate possible pathological (pathological) physical findings.