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It is important to examine a stuporous patient when he is in stupor rather than waiting for the clinical picture to change or for the patient to become more accessible. The systematic way to examine a stuporous patient are: 1. General Reaction and Posture 2. Facial Expression 3. Eyes 4. Reaction to what is said or done 5. Muscular Reactions 6. Emotional Responsiveness 7. Speech 8. Writing.
Way # 1. General Reaction and Posture:
(a) Attitude:
Attitude voluntary or passive.
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(b) Voluntary postures:
Voluntary postures comfortable, natural, constrained.
(c) What does the patient do if placed in awkward or uncomfortable positions?
(d) Behaviour toward physicians and nurses:
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Resistive, evasive, irritable, apathetic, complaint.
(e) Spontaneous acts:
Any occasional show of playfulness, mischievousness or assaultiveness. Defence movements when interfered with or when pricked with pin. Eating and dressing. Attention to bowels and bladder. Do the movements show only initial retardation or are they consistent throughout.
(f) To what extent does the attitude change ? Is the behaviour constant or variable from day to day? Do any special occurrences influence the condition?
Way # 2. Facial Expression:
Alert, attentive, placid, vacant, stolid, scowling, averse, perplexed, distressed, etc. Any play of facial expression or signs of emotions tears, smiles, flushing, perspiration. On what occasions?
Way # 3. Eyes:
Open or closed, resist having lid raised. Movement of eyes absent or obtained on request; give attention and follow the examiner or moving objects; or show only fixed gazing, furtive glances or evasion.
Rolling of eye balls upward. Blinking flickering, or tremor of lid. Reaction of sudden approach of threat to stick pin in eye. Sensory reaction of pupils (Dilation from painful stimuli or irritation to skin of neck).
Way # 4. Reaction to what is said or done:
a. Commands:
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Show tongue, move limbs, grasp with hand (clinging, clutching, etc.)
b. Motions slow or sudden:
Reaction to pinpricks. Automatic obedience and tell patient to protrude the tongue to have pin stack into it. Echopraxia; imitation of actions of others.
Way # 5. Muscular Reactions:
Test for rigidity: muscles relaxed or tense when limbs or body is moved. Catalepsy, waxy flexibility. Negativism shown by movements in opposite directions or springy or cog wheel resistance. Test head and neck by movements forward and the lower extremities. Does distraction of command influence the reactions? Closing of mouth, protrusion of lips (Schnauzkrampf).
Way # 6. Emotional Responsiveness:
Is feeling shown when talked to family or children.
Or when sensitive points in history are mentioned or when visitors come. Note whether or not acceleration of respiration or pulse occurs; also look for flushing, perspiration, tears in eyes, etc. Do jokes elicit any response? Effect of unexpected stimuli (clap hands, flash of electric light).
Way # 7. Speech:
Any apparent effort to talk, lip movements, whispers, movements of head. Note exact utterances with accompanying emotional reaction (may indicate hallucinations).
Way # 8. Writing:
Offer paper and pencil. If responsive or partially stuporose patient will often write when they fail to talk.
Diagnostic Formulation:
It consists of:
i. Summary of patient’s problems.
ii. Salient features of genetic, constitutional, familial and environmental influences.
iii. Important findings (positive and negative) on mental examination.
iv. Provisional diagnosis and differential diagnosis.
Treatment Plan:
It should stress on:
i. The problems needing urgent attention (e.g., excitement, stupor, suicidal ideation etc.).
ii. The reasons for hospitalization (if any).
iii. Investigations or tests required.
iv. Treatments e.g., medication (injectable or oral), physical treatment (electroconvulsive therapy), psychotherapy, behavioural modification, counselling of relatives etc., and their duration.
v. Prognosis:
Favourable and poor prognostic factors.