Altered Mental Status

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a decreased level of consciousness that began ‍ ‍days ago

Onset was ‍gradualsuddenprogressive

Last known normal ‍ ‍days ago

Witnessed by ‍family membersbystandersno one, and described as ‍lethargicstuporouscomatose

Associated symptoms:

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

confusion

aphasia

weakness

seizure

‍fever, up to ‍°, over ‍ ‍hoursdays

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍shortness of breath

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

trauma

depression

‍suicidal thoughts, ‍persistentintermittent, ‍withwithout a plan, ‍withwithout intent to act





Contributing factors:

‍recent head injury

no history of: ‍diabetes, ‍cardiac disease, ‍epilepsy, ‍psychiatric disorders, ‍substance use

no use of: ‍antiepileptics, ‍antidepressants, ‍antipsychotics, ‍sedatives, ‍opioids





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Head: ‍normocephalicatraumatic, scalp ‍normalrashlesion

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM

Neurologic:

- Mental status: ‍alert, oriented to ‍3 spheres, speech ‍intact

- Cranial nerves: ‍all intact

- Strength: ‍intact 5/5 throughout except for ‍4/5 on ‍rightleft ‍, ‍pronator drift

- Sensation: ‍intact throughoutdecreasedabsent to ‍light touch on ‍

- Reflexes: ‍intact 2+ throughout except for ‍1+ on ‍rightleft ‍, ‍plantar downward

- Cerebellar function: ‍intact, ‍normalimpaired finger-nose, ‍normalimpaired rapid alternating movements, ‍normalimpaired heel-shin, Romberg ‍negative, Dix-Hallpike ‍negative

- Gait: ‍steadyunsteady, ‍intactimpaired tandem gait, ‍intactimpaired heel walk and toe walk





ASSESSMENT:

‍Altered mental status ‍likelysuspectedpossible

DDx: syncope, seizure, stroke, hypoglycemia, intoxication, infection (e.g., meningitis, encephalitis, sepsis), head trauma, subdural hematoma, intracerebral hemorrhage, brain tumor, hydrocephalus, postictal state, metabolic encephalopathy, hypoxia, hypercapnia, electrolyte imbalance, hepatic encephalopathy, uremic encephalopathy, thyroid storm, myxedema coma, adrenal crisis, heat stroke, hypothermia, drug overdose, alcohol withdrawal, sedative-hypnotic withdrawal, psychiatric conditions (e.g., catatonia), dementia with acute decline, delirium, carbon monoxide poisoning, anemia, cardiac arrest, shock, status epilepticus





PLAN:

Investigations:

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍glucose, ‍TSH, ‍calcium, ‍magnesium, ‍albumin, ‍ammonia, ‍liver function tests (LFTs), ‍arterial blood gas (ABG), ‍toxicology screen, ‍β-hCG

- Urinalysis

- Chest X-ray

- ECG

- CT scan of the head

- MRI of the brain

- EEG

- Lumbar puncture

Treatments:

- ‍Airway management

- ‍Breathing support

- ‍Circulation support

- ‍Glucose control

- ‍Electrolyte correction

- ‍Seizure management

- ‍Temperature control

- ‍Toxin removal

Further care:

- Continuous monitoring of vital signs

- ICU admission

- Referral to neurology

- Referral to toxicology

- Referral to critical care

- Follow-up in ‍ ‍hoursdays

- Return if level of consciousness decreases further or if new symptoms such as seizures, focal neurological deficits, or respiratory distress develop