Altered Mental Status
Questions
247.A 69-year-old woman with a past medical history of hypertension,
hypercholesterolemia, diabetes mellitus type 1, and alcohol abuse is brought
to the emergency department (ED) by her daughter who states that her
mom has been acting funny over the last hour. She states that the patient
did not know where she was despite being in her own house. She also did
not recognize her family and was speaking incomprehensibly. Her blood
pressure (BP) is 150/80 mm Hg, heart rate (HR) is 90 beats per minute, tem-
perature is 98.9°F, and her respiratory rate (RR) is 16 breaths per minute.
On physical examination she is diaphoretic, agitated, and tremulous. Elec-
trocardiogram (ECG) is sinus rhythm with normal ST segments and T waves.
Which of the following is the most appropriate course of action for this patient?
a. Administer a benzodiazepine to treat her ethanol withdrawal.
b. Activate the stroke team and bring the patient directly to the computed tomo-
graphic (CT) scanner.
c. Get a stat fingerstick and administer dextrose if her blood sugar is low.
d. Request a psychiatric consult for probable sundowning.
e. Administer haloperidol for sedation.
248.A 74-year-old lethargic woman is brought to the ED by her family. Her
daughter states that the patient has been progressively somnolent over the
last week and could not be woken up today. The patient takes medications
for diabetes, hypertension, hypothyroidism, and a recent ankle sprain, which
is treated with a hydrocodone/acetaminophen combination. In the ED, the
patient is profoundly lethargic, responsive only to pain, and has periorbital
edema and delayed relaxation of the deep tendon reflexes. Her BP is
145/84 mm Hg, HR is 56 beats per minute, temperature is 94.8°F, and RR is
12 breaths per minute. Which of the following is the most likely diagnosis?
a. Hypoglycemia
b. Opioid overdose
c. Stroke
d. Myxedema coma
e. Depression
267