Sandbox:M.Romo

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