myocardial infarction or septicemia or Addson's disease. 9. RESPIRATION - Slow, shallow breathing suggests dug intoxication Deep and rapid respiratio

to depressive illness B. General examination - 1 GENERAL APPEARANCE - Flushed face In alcoholic, pale yellow In uremia, cherry red In carbon monoxide poisoning Cold clammy skin suggests hyperinsulinism or morphine poisoning, pigmentation of skin and buccal mucosa in Addison's disease. petechiae in skin suggestive of cerebral embolism Fever - usually Indicates a systemic infeciion, meningitis, cerebral malaria, encephalitis or cerebral abscess. 2. ODOUR - of alcohol acetone in diabetes, ammoniacal in uremia, and of drug like cyanide Foetor hepaticus in hepatic coma Pungent odour in organo-phosphorus poisoning 3 HEAD - Depressed fracture of skull may be palpable. 4. EARS - Blood may suggest basal fracture Midde ear infection or tenderness and swelling over mastoid may indcate an intercranial abscess EYES-(a)Jaundice in liver failure. (b) Soft eyeballs In diabetic acidosis. (c) Resistance to opening of eyes and rolling up of eye balls in hysterical coma. 6. HYPOTHERMIA 'following exposure to low temperatures. intoxication wtih alcohol or hypnotics, profound myxoedema or peripheral circulatory failure. 7 TACHY or BRADYARRHYTHMAS. or evidence of valvular heart dsease or peripheral emboli suggest cardogenic cause. Bruits over carotids suggest cerebro vascular disease. 9. HYPOTENSION - Possibility of shock, myocardial infarction or septicemia or Addson's disease. 9. RESPIRATION - Slow, shallow breathing suggests dug intoxication Deep and rapid respirations suggest pneumonia or metabolic acidosis Periodic respiration suggests cardiac or brainstem lesion. 10 ENLARGEMENT OF AN ABDOMINAL ORGAN - might indcate portal hypertension, polycystic kidneys and an associated SAH. 11. PURPURA - suggests a bleedng dathesis. and bruising around the head possible trauma or fracture at base of skull. 12. RASH - may indcate an Infective or inflammatory dsease. 13. EVIDENCE OF PUNCTURE WOUNDS - may identify a diabetic patient or a drug user. C. Neurological examination 1 Observation and assessment of reflex responses - (a) Position, posture and spontaneous movements of the patient should be noted (bj Examination of skull and spine, and tasting for neck stiffness and Kernig's sign identity meningeal Irritation. 2. Level of consciousness - Most useful is the Glasgow Coma Scale. Supra-orbital pressure is a useful central stimulus and nail bed pressure a peripheral one All four limbs are observed for responses to pain and the best response is recorded Asymmetry should be noted and is important in identifying localization. BRAIN STEM FUNCTION 1. Pupils Normally reacting pupils -Metabolic causes or drug overdosage. (except glutethimde and armphetamine). (ii) Unequal pupils - Unless proved otherwise, a dilated pupil indicates a hemiated temporal lobe stretching the 3rd nerve on that side (III) Bilateral dilaled pupils - End stage of progressive tentoria! herniation. Also glutethimide atropine and amphetamine poisoning. (iv) Bilateral pinpoint pupils - Intrapontine hiemorrage, opiates. 2. Corneal response -is usually retained until very deep coma If it is absent in patient in light coma, the cause of corna may be drug intoxication Loss of corneal riflex in absence of drug overdosage is a poor prognostic indsator 3 Spontaneous eye movements - (a) Conjugate deflation of the eyes suggests afocal hemispheric or brainstem lesion. (b) Depression of eye movements may occur In midbrain damage at level of the tectum and occasionally in metabolic coma (c) Skew deviation suggests a lesion at pontomedullary junction. (d) Dyacangugate eyes.