Welcome to "The Pulse", a blog of educational activities at TGH. This blog was started by Isaac Bogoch last year and will be continued onwards this year. All errors, omissions and mis-representations are his.

Today at morning report, we discussed the approach to a patient with an altered level of consciousness. The facilitator provided a framework for the differential diagnosis:

1. Neurologic causes - including stroke, CNS infections, dementing illnesses such as Lewy Body dementia, normal pressure hydrocephalus and others.

2. Metabolic causes - including electrolyte abnormalities (think sodium and calcium!), endocrinopathies (e.g. thyroid disease).

3. Medications - overdose, intoxication, withdrawal. Also consider over-the-counter and alternative therapies.

4. Major medical illness. Both liver and kidney dysfunction can present with altered level of consciousness.

5. Psychiatric illness. Depression can present in atypical ways, particularly in the elderly.

We also talked about the basics of the workup and management of stroke. A good general review article on stroke can be found in the New England Journal of Medicine 2007, Vol 357 (6), pp 572-579. A link to the abstract is found here

I would encourage you to consult the Canadian Stroke Network best practice guidelines on stroke management, linked here. Although practice guidelines often represent a combination of evidence and expert opinion, they can be helpful resources and can direct you to the peer-reviewed literature.

Hope you are all enjoying the first week. Let me know how I can help make this a great experience for you!

Shannon