Diagnosis Of Altered Mental Status Research Articles

Alerting providers to hospitalized persons with dementia using the electronic health record.

While patients with dementia entering the hospital have worse outcomes than those without dementia, early detection of dementia in the inpatient setting is less than 50%. We developed and assessed the positive predictive value (PPV) and feasibility of a novel electronic health record (EHR) banner to identify patients with dementia who present to the inpatient setting using data from the medical record. We developed and implemented an EHR algorithm to flag hospitalized patients age ≥65 years with potential cognitive impairment in the Epic EHR system using dementia ICD-10 codes, FDA-approved medications, and the use of the term "dementia" in the emergency department physician note. Medical records were reviewed for all patients who were flagged with an EHR banner from October 2022 to May 2023. A total of 344 individuals were identified who had a banner on their chart of which 280 (81.4%) were either diagnosed with dementia or were on an FDA-approved dementia medication. Forty-three individuals who had confirmed dementia were identified by a medication only (15.4%). Of the patients without confirmed dementia, the majority (N = 33, 9.6%) had a diagnosis of altered mental status, cognitive dysfunction, or mild cognitive impairment. Only 31 individuals (9.0%) had no indication of dementia or cognitive decline in their problem list, past medical history, or medication list. We found that it was feasible to implement an EHR algorithm for prospective dementia identification with a high PPV. These types of algorithms provide an opportunity to accurately identify hospitalized older individuals for inclusion in quality improvement projects, clinical trials, pay-for-performance programs, and other initiatives.

Myxedema Coma: A Rare Case Report of Severe Hypothyroidism in Uganda

Objective: in this report, we describe a case of myxedema coma in a 46-year-old Ugandan lady who had never before had hypothyroidism. Investigations and Medical Care: The patient's first presentation included bradycardia, hypothermia, and a noticeably low Glasgow Coma Scale score. Laboratory examinations revealed severe primary hypothyroidism. Intravenous levothyroxine, hydrocortisone, and supportive care were the first steps in the treatment. Results: After receiving therapy for one week, the patient achieved a full recovery. Thyroid function tests showed improvement back to normal range. Conclusion: This case highlights the importance of considering myxedema coma in the differential diagnosis of altered mental status, even in resource-limited settings. Increased awareness, prompt diagnosis, and appropriate treatment can be life-saving in these cases.

Detection of delirium in three steps - From Screening to Verification to Etiology

Clinicians are commonly confronted with the differential diagnosis of altered mental status, impaired cognition and altered level of consciousness in hospitalized patients including those admitted to medical, geriatric, emergency, intensive and post-operative care units. Although delirium is the most common acute neuropsychiatric condition in the acute hospital setting this diagnosis is commonly delayed, made too late or missed altogether. The causes of delirious states are manifold. Both, direct damage to the brain tissue as well as encephalopathy as a result of other medical diseases, can be the cause of delirium. Depending on the predisposition delirious syndromes can be provoked by minor medical interventions. Clinical presentation is very variable, but remains largely independent of the triggering mechanisms. Purely catatonic, hypoactive, hyperactive and excitatory types as well as mixed forms can be distinguished.Immediate diagnosis of a delirious syndrome and rapid elucidation of its causes are keys for the implementation of curative therapy. There is a need to act fast because delirious phases are associated with significantly longer hospital stay and increased morbidity as a result of long-term cognitive deficits as well as increased mortality. As negative outcome is closely linked to the duration of a delirious episode, early diagnosis and rapid termination of the delirium constitute a significant positive predictor of outcome. In this respect, delirium represents an emergency, with or without concomitant cerebral or extracerebral symptoms.

Pediatric Emergency Medicine Simulation Curriculum: Marijuana Ingestion.

Altered mental status can be a challenging presenting symptom in children due to the wide differential diagnosis, which ranges from the relatively benign to the life threatening. Marijuana ingestion and unintentional intoxication are becoming an increasingly common cause of altered mental status in children as marijuana use and availability of enticing marijuana edibles increase in the United States. Because children present with altered mental status rather than the typical marijuana toxidrome, appropriately managing these patients in emergency settings can be particularly challenging. This simulation-based curriculum involved the evaluation and management of a 6-year-old boy who presented with altered mental status from acute marijuana intoxication unbeknownst to his parents. Participants systematically evaluated a pediatric patient with a broad differential diagnosis of altered mental status and managed the patient with acute marijuana intoxication. This scenario may be modified based on trainee level (medical student vs. resident vs. fellow). A total of 20 trainees comprising six emergency medicine fellows and 14 pediatric residents and medical students participated in this simulation curriculum over three iterations. Trainees consistently rated it as an overall positive learning experience for pediatric altered mental status and toxidrome education. Low-frequency, high-risk illnesses such as altered mental status due to marijuana intoxication require providers to be familiar with their evaluation and management. This curriculum provides instructors with the materials to successfully implement and improve the simulation over time.

School Nurses on the Front Lines of Medicine: Uppers and Downers: The Approach to the Student With Altered Mental Status.

Although a student presenting with altered mental status due to substance use may occur infrequently in the school setting, it is of utmost importance to develop a differential diagnosis and to initiate stabilization of the student. This article describes the initial assessment and management of a student presenting with altered mental status, focusing on the differential diagnosis of altered mental status, on the varying presentations associated with common intoxications and ingestions, and on the screening tools available for the detection of depression and substance use.

Electroencephalographic findings in consecutive emergency department patients with altered mental status

Electroencephalography (EEG) can help narrow the differential diagnosis of altered mental status (AMS) and is necessary to diagnose nonconvulsive seizure (NCS). The objective of this prospective observational study is to identify the prevalence of EEG abnormalities in emergency department patients with AMS. Patients of at least 13 years of age with AMS were enrolled, whereas those with an easily identifiable cause (e.g. hypoglycemia) underlying their AMS were excluded. Easily identifiable cause of AMS (e.g. hypoglycemia). A 30-min EEG with the standard 19 electrodes was performed on each patient. Descriptive statistics (%, 95% confidence interval) are used to report EEG findings of the first 50 enrolled patients. Thirty-five EEGs (70%, 57-81%) were abnormal. The most common abnormality was slowing of background activities (46%, 33-60%), reflecting an underlying encephalopathy. NCS was diagnosed in three (6%, 1-17%), including one patient in nonconvulsive status epilepticus. Nine patients (18%, 10-31%) had interictal epileptiform abnormalities, indicating an increased risk of spontaneous seizure. Patients presenting to the emergency department with AMS have a high prevalence of EEG abnormalities, including NCS.

Acute Lithium Intoxication

Lithium is known for its efficacy and toxicity. Toxic effects have been characterized even with therapeutic levels. Most physicians will at some point be faced with a patient with altered mental status and no records of his or her history. The differential diagnosis of altered mental status is long, and further lengthens in a patient with a psychiatric history. Since several life-threatening complications of psychotropic medications exist, physicians must be astute with their diagnoses. Lithium toxicity, neuroleptic malignant syndrome, and the serotonin syndrome can present similarly and require rapid recognition. We present a case of lithium toxicity in a patient who presented with altered mental status and a paucity of history information.

A case of limbic encephalitis presenting as a paraneoplastic manifestation of limited stage small cell lung cancer: a case report

IntroductionThe differential diagnosis of altered mental status and behavioral change is very extensive. Paraneoplastic limbic encephalitis is a rare cause of cognitive impairment, which should be considered in the differential diagnosis.Case presentationA 64-year-old British Caucasian woman presented to our hospital with a 12-week history of confusion and short-term memory loss. She was hyponatremic with a serum sodium level of 128mmol/L. Moreover, there was evidence of left hilar prominence on the chest radiograph. A thoracic computed tomography scan showed left hilar opacity with confluent lymphadenopathy. A percutaneous biopsy confirmed a diagnosis of small cell lung cancer. There was no radiological evidence of brain metastasis on the computed tomography scan. In view of continued cognitive impairment, which was felt to be disproportionate to hyponatremia, a magnetic resonance imaging scan of the brain was undertaken. It showed hyperintense signals from both hippocampi, highly suggestive of limbic encephalitis presenting as a paraneoplastic manifestation of small cell lung cancer. She had a significant radiological and clinical response following chemotherapy and radiotherapy.ConclusionThis case highlights the importance of considering paraneoplastic syndromes in patients with neurological symptoms in the context of lung malignancy. If initial investigations fail to reveal the cause of cognitive impairment in a patient with malignancy, magnetic resonance imaging may be invaluable in the diagnosis of limbic encephalitis. The clinical presentation, diagnostic techniques and management of paraneoplastic limbic encephalitis are discussed in this case report.

Detection of regional blood perfusion changes in epileptic seizures with dynamic brain perfusion CT—A pilot study

Background and purpose Perfusion CT (P-CT) is used for acute stroke management, not, however, for evaluating epilepsy. To test the hypothesis that P-CT may identify patients with increased regional cerebral blood flow during subtle status epilepticus (SSE), we compared P-CT in SSE to different postictal conditions. Methods Fifteen patients (mean age 47 years, range 21–74) underwent P-CT immediately after evaluation in our emergency room. Asymmetry indices between affected and unaffected hemispheres were calculated for regional cerebral blood volume (rCBV), regional cerebral blood flow (rCBF), and mean transit time (MTT). Regional perfusion changes were compared to EEG findings. Results Three patients in subtle status epilepticus (group 1) had increased regional perfusion with electro-clinical correlate. Six patients showed postictal slowing on EEG corresponding to an area of regional hypoperfusion (group 2). CT and EEG were normal in six patients with a first epileptic seizure (group 3). Cluster analysis of asymmetry indices separated SSE from the other two groups in all three parameters, while rCBF helped to distinguish between chronic focal epilepsies and single events. Conclusion Preliminary results indicate that P-CT may help to identify patients with SSE during emergency workup. This technique provides important information to neurologists or emergency physicians in the difficult clinical differential diagnosis of altered mental status due to subtle status epilepticus.

New-onset absence status epilepsy presenting as altered mental status in a pediatric patient

Absence status epilepsy (ASE) is an uncommon seizure disorder in children. The primary presentation of new-onset ASE in a pediatric patient is an unusual cause of altered mental status in the emergency department. We describe a previously healthy 8-year-old child who presented with an acutely altered mental state. The patient was awake but confused, with a fluctuating level of alertness and an inability to perform simple routine tasks. The results of general physical and neurologic examination, with the exception of mental status, were normal. Head computed tomography and laboratory test results were normal. Electroencephalographic testing revealed seizure activity consistent with ASE. Administration of intravenous diazepam caused cessation of seizure activity and a return to the patient’s baseline mental function. Although rare, ASE should be considered in the differential diagnosis of altered mental status in children. [Benson PJ, Klein EJ. New-onset absence status epilepsy presenting as altered mental status in a pediatric patient. Ann Emerg Med. April 2001;37:402-405.]

Cerebral Embolization Presenting as Delayed, Severe Obtundation in the Postanesthesia Care Unit After Total Hip Arthroplasty

Catastrophic neurologic events occur rarely postoperatively and must be diagnosed quickly. A 63-year-old woman who had undergone uneventful total hip arthroplasty experienced obtundation after admission to the postanesthesia care unit. Cranial magnetic resonance imaging revealed multiple lesions consistent with ischemia or infarction, and fat cerebral embolism was diagnosed. We describe the numerous complications that may occur in patients in the postanesthesia care unit and review the differential diagnosis of altered mental status in such patients. Paradoxical cerebral fat embolization must be considered in the differential diagnosis of altered mental status after pelvic or long bone fracture or lower extremity major joint replacement, and this condition may occur despite normal pulmonary function and no patent foramen ovale or right-to-left intracardiac shunt. Magnetic resonance imaging with T2-weighted sequences is the cranial imaging study of choice for early evaluation of patients with sudden multifocal neurologic deficits and suspected fat embolism syndrome.

Trimethoprim-Sulfamethoxazole-Induced Hypoglycemia as a Cause of Altered Mental Status in an Elderly Patient

Drug-induced hypoglycemia is an important consideration in the differential diagnosis of altered mental status, especially in the elderly patient. Symptoms can be insidious, causing subtle mental status changes. In addition to the well known hypoglycemic effects associated with treatment of diabetes mellitus, several commonly prescribed medications, such as thiazides, sulfonylureas, and. some antibiotics, can cause hypoglycemia. We describe a case of hypoglycemia in an elderly patient taking sulfonamide antibiotics. Previous reports in the medical literature have described this occurrence with sulfonamides, all in renally impaired patients or in those who were also taking sulfonylurea drugs. Although the incidence of drug-induced hypoglycemia is rare in the general population, its incidence is not uncommon in elderly and diabetic patients.

Acute mental status changes.

Acute changes in mental status can occur in any hospital setting. Clinicians are often at a loss to define accurately the course of a change in mental status, because of poor differentiation in the terminology surrounding this difficult diagnosis. A clear understanding of the differences among several levels of altered mental status is needed to evaluate, accurately diagnose, and treat those patients with altered mental states. The differential diagnosis of altered mental status is diffuse and includes supratentorial mass lesions, infratentorial mass lesions, and metabolic disorders. Development of an individualized differential diagnosis and diagnostic approach for cases of altered mental status represents a challenge to all levels of clinicians.

Severe Hypomagnesemia Associated with Pentamidine Therapy

A case of severe hypomagnesemia in a patient with AIDS that manifested as changes in mental status is presented. The hypomagnesemia was due to renal wasting of magnesium, most probably caused by pentamidine-induced renal tubular injury. This entity has been reported once before and should be considered in the differential diagnosis of altered mental status in patients with AIDS.

Acute psychosis after amantadine overdose

Amantadine is an antiviral agent that is also used in the treatment of parkinsonism and neuroleptic-induced extrapyramidal symptoms. Toxic effects of amantadine relate primarily to the central nervous system and range from mild symptoms to disorientation and hallucinations. Anti-cholinergic agents may exacerbate these effects. We report a case of unsuspected amantadine overdose in a previously healthy 35-year-old woman who presented with acute psychosis manifested by delirium and visual hallucinations. Concomitant use of diphenhydramine contributed to the clinical presentation. Amantadine toxicity should be considered in the differential diagnosis of altered mental status in patients known to be taking the drug or with conditions commonly treated with amantadine.