Basic approach to patient presenting with altered mental status

1. By Dr. Nauman Zafer PGR Medicine

2.  Vague but commonly used term that is
applied to both alteration in level of
consciousness and alteration in cognitive
function
 Quick assessment is made using AVPU scale
or Glasgow coma scale (GCS)
 Detailed evaluation may require mini–mental
state examination (MMSE)

3. A
The patient is alert
V
The patient responds
to verbal stimulation
P
The patient responds
to painful stimulation
U
The patient is
completely
unresponsive

4. Best eye response (E) Best verbal response
(V)
Best motor resposnse
(M)
4 Eyes opening
spontaneously
5 Oriented 6 Obeys commands
3 Eyes opening to
speech
4 Confused 5 Localizes to pain
2 Eye opening in
response to pain
3 Inappropriate words 4Withdraws from pain
1 No eye opening 2 Incomprehensible
sounds
3 Flexion in response to
pain
1 None 2 Extension in response
to pain
1 No motor response

5.  30-point questionnaire
 It is used to measure cognitive impairment
 Serial measurements can document further
decline in cognition or response to treatment

6.  Drugs and drug withdrawal
 Sedatives (Benzodiazepines, Opioids,
Alcohol)
 Withdrawal of sedating drugs (e.g. delirium
tremens due to alcohol withdrawal)
 Infections
 CNS infections (Meningitis, Encephalitis,
Brain abscess)
 Others (UTI, RTI, Sepsis)

7.  Metabolic and Electrolytes
 Metabolic
Hypo/hyperglycemia,Acidosis, Liver disease,
Kidney disease,Addison disease,
Thyrotoxicosis, Myxedema coma
 Electrolyte Disturbances
Hyper/hyponatremia, Hypercalcemia,
Hyper/hypomagnesemia, Hypophosphatemia

8.  Tumor
 CNS tumors
 Trauma
 Concussion, Contusion
 Vascular
 Systemic (Hypertension, Hypotension,
Shock)
 Local (CVA,Vasculitis)

9.  Others
 Defeciencies of vitamins (B12, Niacin,
Thiamin)
 Environmental (Hyper/hypothermia)
 Acute CO2 retention
 Toxins (Organophosphates, CO)
 Hypoxemia

10.  Emergency department management, initial
resuscitation
 Detailed history, examination, investigations
 General Nursing care

11. CABG
C circulation
A airway
B breathing
G glucose

12.  Should be performed parallel with or after
initial resuscitation
 Complete history, GPE and complete
systemic examination for cause and
complications

13.  CBC
 LFTs, RFTs
 Na, Ca, Mg, PO4
 ESR, CRP
 ABGs
 ECG
 Urine C/E

14.  CXR
 CT scan brain
 USG abdomen, pelvis, KUB

15. Additional as required
 MRI brain
 Peripheral blood picture
 B12 levels
 Urine C/S
 EEG
 TFTs
 AFB smear, C/S, Xpert MTB/RIF on body fluids

16. Hydration
Nutrition
Physiotherapy
General hygiene and skin care
Bowel and Bladder care
Oral hygiene
Grooming

17. DVT prophylaxis
Bed sores prevention
Chest physiotherapy, Postural drainage,
Suction
Care of catheter sites

18.  Treatment of cause
 Treatment of complications