Sandbox:M.Romo

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Patient with altered mental status (Amnesia, confusion, loss of alertness, disorientation, disruption of judgement, behavior and perception)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate ABCDEF
• Airway
• Breathing
• Circulation
• Disability (Glasgow coma scale)
• Exposure (Rapid head to toe revision)
• Fingerstick blood glucose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check vital signs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable?
 
Yes
 
Stabilize
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Combative?
 
Yes
 
Apply physical or chemical restrain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wernicke encephalopathy suspected?
 
Yes
 
Administer thiamine
 
Improvement
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypoglicemic?
 
Yes
 
Administer dextrose
 
Improvement?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Opioid intoxication suspected?
 
Yes
 
Administer naloxone
 
Improvement?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform physical examination with full neurologic evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order CBC, electrolyte panel, liver and kidney function tests (including albumin), urinalysis, urine culture, urine toxicology screen, chest x-ray, EKG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspected neurodegenerative disease?
 
Yes
 
Perform minimental exam
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive for neurodegenerative electrolyte imbalance, hepatic encephalopathy, urinary infection, pneumonia, drug intoxication?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform non-contrasted CT scan of the brain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive for stroke or structural causes (hidrocephalus, neoplasms)?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform lumbar puncture
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive for neuro infection or subarachnoid hemorrhage?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspicious for status epilepticus?
 
Yes
 
Perform EEG
 
Positive for status epilepticus?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order the following tests guided by findings of the evaluation:

Serum ammonia, thyroid function tests, morning cortisol, vitamin B12, arterial blood gas, sedimentation rate, autoimmune serologies including antinuclear antibodies, thyroperoxidase

and thyroglobulin antibodies, blood cultures, extended toxicology screen, blood gas analysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive for sepsis, intoxication, overdose, withdrawal, concusion, Hashimoto encephalopathy, hypothyroidism, uremic encephalopathy, porphyria, B12 deficiency, autoimmune encephalitis, carbon monoxide intoxication?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform a thorough psychiatric evaluation to rule out psychiatric conditions