patient medical report with medical terms for patient with coma

What does coma mean in medical terms?

Overview. A coma is a medical emergency. Swift action is needed to preserve life and brain function. Doctors normally order a battery of blood tests and a brain CT scan to try to determine what's causing the coma so that proper treatment can begin. A coma seldom lasts longer than several weeks.

What is the focus of the physical exam for coma?

The focus of the examination is to distinguish metabolic causes for coma from structural ones, since the former generally require supportive medical care, whereas the latter may require urgent surgical intervention.

What are the signs and symptoms of a coma?

The signs and symptoms of a coma commonly include: A coma is a medical emergency. Seek immediate medical care for the person in a coma. Many types of problems can cause a coma. Some examples are: Traumatic brain injuries. These are often caused by traffic collisions or acts of violence.

How long does a coma last?

A coma seldom lasts longer than several weeks. People who are unconscious for a longer time might transition to a persistent vegetative state or brain death. The signs and symptoms of a coma commonly include:

What is the medical term for being in a coma?

Publications. Definition. A coma, sometimes also called persistent vegetative state, is a profound or deep state of unconsciousness. Persistent vegetative state is not brain-death. An individual in a state of coma is alive but unable to move or respond to his or her environment.

How will you assess the patient with coma?

Cranial nerves V and VII can be assessed in comatose patients by testing corneal reflexes and by observing facial grimacing in response to noxious stimulation, such as supraorbital pressure. Cranial nerves IX and X can be assessed by testing the gag reflex, although this may be absent in 20% of normal subjects.

How do you document Loc?

To accurately determine LOC, use objective criteria, such as eye opening, motor response, and verbalization, both spontaneously and on command. These three criteria are used in the Glasgow Coma Scale, designed primarily for patients with impaired consciousness following brain injury.

What does GCS 7t mean?

Certain scores on the Glasgow Coma Scale have significance. Patients with a Glasgow Coma Scale score of 7 or less are considered comatose. Patients with a Glasgow Coma Scale score of 8 or less are considered to have suffered a severe head injury.

How do you observe an unconscious patient?

OverviewCheck the person's airway, breathing, and circulation.If you do not think there is a spinal injury, put the person in the recovery position: Position the person lying face up. Turn the person's face toward you. ... Keep the person warm until emergency medical help arrives.

What types of comas are there?

What Are The Different Categories of Comas?Toxic-Metabolic Encephalopathy. When the kidneys or other organs fail, the body fails to dispose of any toxins correctly. ... Cerebral Hypoxia. ... Persistent Vegetative State (PVS) ... Locked-In Syndrome. ... Brain Death. ... Medically Induced Coma.

How do you document a patient to sleep?

More Like This. I always say, simply, "pt is resting quietly". I always charted..."pt resting with eyes closed, no distress noted, RR regular and nonlabored." We did vital signs q 4 hr also.

What does A and O times 4 mean?

A&Ox4 (also AAOx4 – awake,alert and oriented) refers to someone who is alert and oriented to person,place, time and event. Does the person being evaluated understand who they are, where they are, approximate date or part of the day, and what is happening?

How would you describe the level of consciousness?

Consciousness is an awake state, when a person is fully aware of his or her surroundings and understands, talks, moves, and responds normally. Decreased consciousness is when a person appears to be awake and aware of surroundings (conscious) but is not responding normally.

What does GCS 10 mean?

Severe: GCS 8 or less. Moderate: GCS 9-12. Mild: GCS 13-15.

What does GCS 15 mean?

The GCS is the summation of scores for eye, verbal, and motor responses. The minimum score is a 3 which indicates deep coma or a brain-dead state. The maximum is 15 which indicates a fully awake patient (the original maximum was 14, but the score has since been modified).

What GCS 40?

A team from the Institute of Neurological Sciences updated the GCS and developed a Structured Approach to Assessment to minimize variation in stimulation and response measurement.

Who Writes the Patient Medical Report?

Health care providers do the patient medical report. The health care professionals make the documentation for a patient. It includes all the physic...

Who Can Have Access to a Patient Medical Report?

The health care providers have the access to the patient medical report. They keep the medical report as a history of medical records. Also, patien...

Is a Patient Medical Report a Legal Document?

If it is signed by a health care professional, then it is a legal document. It is permissible in any court of law. It is an evidence that the patie...

What is a coma in medical terms?

A coma is a medical emergency. Doctors will first check the affected person's airway and help maintain breathing and circulation. Doctors might give breathing assistance, intravenous medications and other supportive care. Treatment varies, depending on the cause of the coma.

How to know if you are in a coma?

Speaking loudly or pressing on the angle of the jaw or nail bed while watching for signs of arousal, such as vocal noises, eyes opening or movement. Testing reflexive eye movements to help determine the cause of the coma and the location of brain damage.

How does a coma test work?

This measures the electrical activity inside the brain through small electrodes attached to the scalp. Doctors send a low electrical current through the electrodes, which record the brain's electrical impulses. This test can determine if seizures might be the cause of a coma.

Why do doctors need to rely on physical clues?

Because people in a coma can't express themselves , doctors must rely on physical clues and information provided by families and friends. Be prepared to provide information about the affected person, including: Details about how the affected person lost consciousness, including whether it occurred suddenly or over time.

What to check for in a coma exam?

The exam is likely to include: Checking the affected person's movements and reflexes, response to painful stimuli, and pupil size. Observing breathing patterns to help diagnose the cause of the coma. Checking the skin for signs of bruises due to trauma.

What to do if you are in a coma?

If you are with a person who develops signs and symptoms of a coma, call 911 or your local emergency number immediately . When you arrive at the hospital, emergency room staff will need as much information as possible from family and friends about what happened to the affected person before the coma.

Can you give antibiotics to a diabetic in a coma?

Emergency personnel might administer glucose or antibiotics intravenously, even before blood test results return, in case of diabetic shock or an infection affecting the brain. If the coma is the result of drug overdose, doctors will give medications to treat the condition.

What does coma mean in medical terms?

Coma is from the Greek word koma which means deep sleep . One definition is as follows: 'A state of profound unconsciousness caused by disease, injury, or poison. The patient is unresponsive and cannot be roused.'. It may be a transient phenomenon during acute illness or persist in the long term.

How long does a coma last after a drug overdose?

Coma not due to head injury or drug overdose, lasting longer than six hours - only 10% chance of recovery. Subarachnoid haemorrhage or stroke - <5% chance of recovery.

What is the term for reduced awareness to surroundings?

However, the person can still be partially roused by some stimuli, such as pain. Obtundation - reduced awareness to surroundings. Again the patient can respond to some stimuli - eg, pain. Drowsiness - this is similar to obtundation and probably represents a lesser loss of consciousness.

What is a professional reference?

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our health articles more useful.

Is a reduced consciousness a coma?

However, having a reduced conscious level need not be a comatose state. It could be an intermediate state of consciousness - eg, stupor, drowsiness, etc. Thus, it needs to be distinguished from the following terms: Stupor - similar to coma in that responsiveness is greatly diminished.

Can you open your eyes in a coma?

A minority of coma patients may be able to open their eyes occasionally or groan and withdraw limbs from painful stimuli, but those in 'deep' coma do not exhibit these responses. It is important to remember that being in a coma means being unconscious. However, having a reduced conscious level need not be a comatose state.

What is a Patient Medical Report?

A patient medical report is a comprehensive document that contains the medical history and the details of a patient when they are in the hospital. It can also be given as a person consults a doctor or a health care provider. It is a proof of the treatment that a patient gets and of the condition that the patient has.

What You Should Include in a Patient Medical Report

A patient medical report has some important elements that you should not forget. Include all these things and you can learn how to write a patient medical report.

Importance of a Patient Medical Report

The reason why a patient medical report is always given is because it is important. Here, you can know some of the importance of a patient medical report:

How to Write a Good Patient Medical Report

A doctor is a doctor. They are not writers. They can be caught in a difficulty on how to write a patient medical report. If this is the case, turn to this article and use these steps in making a patient medical report.

Who Writes the Patient Medical Report?

Health care providers do the patient medical report. The health care professionals make the documentation for a patient. It includes all the physicians, nurses, and doctors of medicine. It also includes the psychiatrists, pharmacists, midwives and other employees in the allied health.

Who Can Have Access to a Patient Medical Report?

The health care providers have the access to the patient medical report. They keep the medical report as a history of medical records. Also, patients’ access to the patient medical report is a must. It is their right to see their medical report. It is against the law not to show them their medical report.

Is a Patient Medical Report a Legal Document?

If it is signed by a health care professional, then it is a legal document. It is permissible in any court of law. It is an evidence that the patient is under your care. Thus, it can be used in court as an essential proof. So, keep a patient medical report because you may need it in the future.

What does coma mean in medical terms?

Coma indicates a state in which the patient is not arousable at all to verbal or physical stimuli, and no attempt is made to avoid painful or noxious stimuli.

What is clouding of consciousness?

Clouding of consciousness represents a disturbance characterized by impaired capacity to think clearly and to perceive, respond to, and remember stimuli. Delirium represents a state of disturbed consciousness with motor restlessness and disorientation. Delusions and hallucinations may be present.

Where is the abnormality in the afferent limb?

The abnormality may be in the afferent limb, from the labyrinth and vestibular nerve, or from neck proprioceptors. Alternatively, the lesion may be in the efferent limb, including the medial longitudinal fasciculus (MLF), cranial nerves III and VI, or in the muscles they innervate.

Can a coma patient test for visual acuity?

The cranial nerve examination of the patient in coma should concentrate on the eyes. Although visual acuity cannot be tested, testing of field defects may be performed by assessing response to visual threat. A finger or small object introduced suddenly into the visual field may elicit a response.

What is a medically induced coma?

A medically induced coma is one option doctors may use to protect the brain after serious trauma and help it heal. The ultimate effect on everyday life largely depends on the extent of brain damage from the trauma. It is possible to have lingering disability due to the underlying brain trauma.

Why is a coma not a common procedure?

Ultimately, this state helps decrease brain swelling and protects the brain from further damage. Stroke, status epilepticus, and drug overdose are other potential reasons for medically induced coma. A medically induced coma is not a common procedure. It is usually a last resort when other options for reducing brain swelling have failed.

Why do people go into a coma?

The most common reasons for medically induced coma involve traumatic brain injuries. These brain injuries often result in significant swelling of the brain. The swelling puts pressure on the brain. This reduces blood flow and oxygen supply to the brain, which can damage brain tissue. Inducing a coma allows the brain to rest.

What are the complications of a coma?

Complications that can occur from medically induced coma include: 1 Blood clots 2 Infection, particularly pneumonia and other lung infections 3 Heart problems 4 Pressure sores and weakness from immobility 5 Vivid nightmares and hallucinations

What to expect after a coma?

What to Expect Afterwards. When doctors see improvements in a person’s condition, they will bring them out of the medically induced coma. The process is the reverse of inducing it. Doctors gradually withdraw the drugs while monitoring brain activity and other vital signs.

How long does it take to get out of a coma?

In most cases, medically induced comas are only necessary for a short period of time. Doctors typically use the procedure for a couple of days or for as long as two weeks.

Can a coma be a last resort?

It is not always possible to reduce the risk of complications with medically induced coma. What’s more, it can be difficult to separate complications of medically induced coma from complications of the brain injury itself. Doctors use medically induced coma as a last resort, when the benefit outweighs the possible risks.

Documentation needs

Providers should consider documenting the coma diagnosis, when their patients are comatose.

More information

Please contact the Clinical Documentation Improvement Department with any questions. Further education regarding this topic is available for your team through the CDI department.

Is the Glasgow Coma Scale accurate?

While the Glasgow Coma Scale is a great diagnostic tool there are multiple limitations that can alter the score and not provide an accurate picture of the patient’s brain injury. These include:

Does Glasgow coma scale measure brain injury?

Another significant limitation of the Glasgow Coma Scale, as it was originally developed, is that it does not accurately measure traumatic brain injury in children under 5 years of age. The aptly-named ‘Pediatric Glasgow Coma Scale (PGCS)’ includes modifications for this patient population.

Description

Assessment

Presentation

Useful Focal Indicators of Pathology in Comatose Patients

Aetiology

• Coma is a state of prolonged unconsciousness that can be caused by a variety of problems — traumatic head injury, stroke, brain tumor, drug or alcohol intoxication, or even an underlying illness, such as diabetes or an infection. Coma is a medical emergency. Swift action is needed to preserve life and brain function. Doctors normally order a series...

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Investigations

Management

Prognosis

Persistent Vegetative State