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Med-Spot on Med-Source: Altered Mental Stauts

Med-Spot: ED evaluation of Altered Mental Status (the infamous ΔMS)
  • Definitions
    • Disorders of consciousness: processes that affect arousal functions (reticular activating system), content of consciousness functions (cortex), or combination of both functions.
    • Dementia: content of consciousness dysfunction, usually insidious onset with gradual decline; alertness is preserved
    • Delirium: acute onset of arousal system dysfunction (+ content of consciousness dysfunction); always has an organic cause!
    • Coma: results from disruption of the reticular activating system and/or disruption of bilateral cortical hemispheres; unilateral hemispheric disease does not cause a comatose state.
    • Mini-mental state exam (MMSE) has 5 elements: orientation, registration, attention & calculation, recall, and languageGlasgow coma scale (GCS) has 3 elements: eye opening, verbal response, motor response
  • Differential diagnosis (AEIOU, TIPS) - to be totally honest, I don't find this mnemonic to be all that helpful, but I have heard it from multiple residents and attendings so I thought I'd pass it along.
    • Alcohol (intoxication, withdrawal, Wernicke’s encephalopathy)
    • Electrolytes (hypernatremia, hyponatrema, uremia, hypercalcemia), Endocrinopathy (addison’s crisis, thyroid storm, hypothyroidism, hyperglycemia, diabetic ketoacidosis), Encephalopathy (uremic, hepatic, hypertensive)
    • Insulin (hyperglycemia, hypoglycemia), Infection (meningitis, sepsis, encephalitis)
    • Oxygen (hypoxia, carbon monoxide), Opiates (heroin, narcotics)
    • Uremia
    • Trauma, Toxicology (poisons, medications), Temperature (hypothermia, hyperthermia)
    • Inborn errors of metabolism
    • Psychiatric, Post-ictal state
    • Seizures, Stroke, Space-occupying lesion (intracranial)
  • Approach to the altered patient
    • History: usually obtained from paramedics, family members, friends, etc…
    • Primary survey: the ABCDE approach is crucial when evaluating the altered patient
    • Obtain vital signs and perform a complete exam
    • Special patients:
      • Agitated or uncooperative patients need to be restrained in order to proceed with the evaluation and to protect the staff.
      • Elderly patients: consider medications, co-morbid conditions. Minor infections such as urinary tract infections or pneumonias may cause significant ΔMS in this population.
      • Pediatric patients: consider child abuse, toxic ingestions.

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