Altered Mental Status (AMS): History

00:01 Thinking about the history for altered mental status, it’s important to involve collateral information.

00:07 What do we mean by that? We mean that you should make every effort that you can to talk with family members, to talk with EMS, so whoever brought the patient in, and also to try and access the medical record to see if the patient has any records either in your computer system or potentially if you’re able to access records from other hospitals.

00:25 It’s very important that you get this information from people because A, the patient may not be able to tell you that, and B, if a patient presents with delirium, they may seem pretty normal to you when you see them, but if you speak with family and you find out that they were acting very confused an hour ago, that’s something very important for you to know 'cause the patient may again then later on in the day or in the evening time, become confused again.

00:53 You always wanna ask about any kind of new medications.

00:57 By that I mean, you wanna ask about prescribed medications.

01:00 You wanna ask about medications that someone may have gotten over the counter.

01:04 So anticholinergic medications such as diphenhydramine is a classic one that can cause altered mental status, especially in elderly people who can be more sensitive to those medications.

01:15 And you also wanna ask about any kind of herbal supplement.

01:18 Patients sometimes go ahead and they go to the natural store and they buy medications that they think may be safe for them, but it might interact with another one of their medications or it may cause them to be confused.

01:32 Substance use and abuse is very key to ask about here.

01:36 There’s a lot of substances that can cause patients to be altered.

01:39 Anything ranging from alcohol to benzodiazepines can all cause altered mental status and there’s lots of stuff in between.

01:48 So finding out if a patient uses substances is a very important question to ask.

01:54 Time course is also very important.

01:56 It’s important to note, did this develop over the last few hours? Did this develop over a few minutes? Did this develop over months? Generally, what we’re talking about here is altered mental status that develops over hours to potentially a day or so.

02:11 We’re talking less about the altered mental status that develops over a course of months.

02:17 It’s also important to talk to your patient about any associated symptoms.

02:21 Again, you may need to talk with their collateral information.

02:24 So you might need to talk with their family member about whether or not they’ve had any fevers at home.

02:29 Try and find out from your patient if they’ve had any chest pain, any shortness of breath, was there any seizure activity? So were they observed shaking all over? Were they observed with any kind of incontinence of urine or stool? Did they have any trauma to their mouth? All of those things can be associated with seizure.

02:48 Chest pain and shortness of breath are definitely important things to kind of ascertain from your patient, especially as people get older, chest pain can sometimes be not as prominent as a presenting symptom but can actually be indicative of a patient having a heart attack or an MI.

03:08 When thinking about the physical exam, the most important thing that you can think about are the vital signs.

03:12 I always tell my students and my residents the vitals are vital.

03:16 So it’s very important to make sure that you have a full set of vital signs on all patients who present with altered mental status.

03:22 Fever is a very important vital sign here.

03:25 You wanna see if your patient is febrile or if they’re not febrile.

03:29 Sometimes that means that you have to check a rectal temperature in order to see what their actual temperature is and that’s the most sensitive and accurate core temperature that you can get.

03:39 Blood pressure, also very important.

03:40 A very elevated blood pressure can point you in the direction of a problem in the brain like a hemorrhagic stroke and a very low blood pressure can point you in the direction of sepsis or infection.

03:53 Heart rate, also very important.

03:54 Heart rate is important in thinking about toxidromes.

03:57 So thinking about possible substance use.

04:00 Heart rate also if it’s elevated can make you think about sepsis or infection.

04:05 Oxygen levels, low oxygen level, hypoxia can definitely cause altered mental status and if you noticed that you wanna make sure you put your patient on oxygen.

04:15 And then, last but not least, the respiratory rate.

04:19 Respiratory rate I say is oftentimes, a very overlooked vital sign.

04:23 Respiratory rate is important because an elevated respiratory rate can be a marker of sepsis and then a low respiratory rate, very important because it can be a marker of opioid overdose.

04:37 You wanna look for head trauma.

04:38 Patients who present with altered mental status might not be able to tell you that they hit their head.

04:43 So a very important thing to do is make sure you take your patient’s hat off, make sure you feel all over their head to make sure that they don’t have a big knot on their head or something that would make you think that they’ve had head trauma that they’re not able to communicate to you.

04:57 You wanna try and quantify their altered mental status.

05:00 Are they confused when you’re talking to them or are they not confused? Sometimes like I said, patients when they present with confusion as a chief complaint may not necessarily be confused when you’re seeing them.

05:12 You could think about the GCS score, the Glasgow Coma Scale score can sometimes help you figure out if your patient is altered.

05:19 And generally, just talking with your patient and figuring out their orientation.

05:22 So you wanna ask them the date, you wanna ask them their name, you wanna ask them where they are.

05:27 Sometimes patients can have problems with those questions, especially if they have underlying dementia.

05:32 So sometimes, it’s helpful to ask who the president or you know, a leader of their country might be.

05:39 And sometimes, they might know that rather than knowing the exact date.

05:44 Toxidromes basically are groups of findings which indicate that a patient has ingested or used a certain substance.

05:53 The key things involved in toxidromes are a pupillary exam, are the pupils dilated? Sympathomimetics like cocaine can cause pupillary dilatation.

06:03 The skin exam is very important.

06:05 There are certain overdoses that can cause the skin to be dry, cause the skin to be warm, cause the skin to be red, whereas other things can cause the skin to be pale and cool, and clammy.

06:15 Also involved in a lot of those toxidromes are the temperature.

06:18 There are substances when they’re ingested that can cause elevated temperature as well as lower temperatures.

06:27 So how do we approach altered mental status in a diagnostic capacity? So there are some screening tools that we can use in the Emergency Department.

06:35 One of them is a mini mental status exam and what this basically can help us do is it can help us see if our patient has an underlying delirium and this is a series of questions that require the patient mainly test their ability to pay attention and figure out the questions that are there, and can help us distinguish also between whether or not this is a psychiatric illness that’s causing them to present or whether this is more of an organic cause that’s causing their confusion.

07:03 The quick confusion score is another thing that’s sometimes utilized in the Emergency Department which is basically a series of questions that can help determine whether or not your patient has delirium or not.

07:16 You also wanna send focused blood work for your patient and lab work.

07:20 That generally consists of a CBC, so checking a blood count, a urinalysis, electrolyte analysis.

07:28 Things such as elevated sodium or low sodium, elevated calcium.

07:35 A renal thought failure can also cause a patient to be altered.

07:38 So a patient who has a very elevated BUN level can lead to altered mental status.

07:43 Liver failure can sometimes lead to altered mental status as well.

07:48 If you’re worried that your patient has liver failure, another lab that you wanna check is an ammonia level.

07:53 It’s important to think about the ammonia level.

07:55 The ammonia level actually doesn’t necessarily always correlate with the patient’s symptoms.

08:00 So sometimes, the patient can have a very elevated level of ammonia but may not necessarily correlate with their exam.

08:07 So you definitely wanna think about it in line with your patient.

08:10 So if your patient is very confused and they have an elevated ammonia level, then that’s something you wanna think about.

08:16 If you think your patient may have used a substance that you’re not able to necessarily figure out, you can send a urine toxicologic screen.

08:23 It doesn’t oftentimes make a change or a difference in your patient management in the Emergency Department, but it’s something that can potentially be helpful or potentially help guide you a little bit.

08:34 So there’s lots of different labs that we can think about sending.

08:36 An alcohol level would be another one.

08:38 If you’re concerned that your patient is intoxicated and you wanna see what their alcohol level is, you can go ahead and send that and a urinalysis as well.

08:47 Then you wanna think about focused imaging.

08:51 What this generally means is we’re thinking about whether or not our patient needs a CAT scan of their head.

08:56 This is when it’s important to go ahead and see if they have any evidence of head trauma or if you’re worried that they have a bleed in their brain.

09:03 And in those situations, you wanna go ahead and get a CAT scan of the head Other things that can cause altered mental status, we talked about infectious symptoms that can cause altered mental status.

09:13 So definitely, getting a chest x-ray may reveal a pneumonia.

09:17 If someone is having abdominal pain along with their confusion, you might wanna consider getting a CT scan of the abdomen.

09:24 So there’s lots of different reasons for altered mental status and you wanna make sure that you’re thinking about them in line with choosing whether or not to do certain x-rays or CAT scans.