Altered Mental Status Answers 287use are known risk factors for hemorrhagic stroke. Increasing ICP can result
in cerebral herniation, which has a mortality rate close to 100%. For any
chance of survival, it must be rapidly controlled by intubation, elevation of
the head of the bed, hyperventilation, mannitol, and definitive neurosurgi-
cal intervention.
Cushing syndrome (a)describes the hyperadrenal state associated with
increased production of cortisol, leading to hypertension, truncal obesity,
abdominal striae, and hirsutism. Cullen sign (c)is purplish discoloration
around the umbilicus that results from intraperitoneal hemorrhage. Charcot
triad(d)constitutes fever, right upper quadrant (RUQ) pain, and jaundice
and is associated with cholangitis. Chvostek sign (e), associated with hypocal-
cemia, is twitching of the nose or lips with tapping of the facial nerve.
261.The answer is c.(Tintinalli, p 1415.)This patient presents with
alcohol withdrawal. Signs and symptoms of this condition occur along a
continuum ranging from simple shakes to delirium tremens (DTs) follow-
ing a reduction or cessation of alcohol. Early symptoms usually appear 6 to
8 hours after cessation of drinking and involve tremulousness, anxiety,
mild hypertension, and tachycardia. In more severe withdrawal, these symp-
toms worsen and paranoia, auditory, and visual hallucinations may develop pro-
ceeding to DTs with severe autonomic hyperactivity and profound altered
mental status. DTs usually occur 3 to 5 days after alcohol cessation and carry 5%
to 15% mortality even with supportive care. Additionally, alcohol withdrawal
seizures may occur anywhere from 6 to 48 hours after cessation of alcohol.
Benzodiazepinesare the mainstay of therapy in alcohol withdrawal, as well as
in sympathomimetic overdose and sedative-hypnotic withdrawal.
Acetaminophen(a)and labetalol (e)would treat the symptoms of low-
grade fever and hypertension/tachycardia, respectively, without addressing
the underlying etiology. Folate (b)should be given to all potentially under-
nourished patients, especially alcoholics, to prevent folate-deficient anemia.
Dextrose was just administered by EMS without symptom improvement;
however, fingerstick glucose (d)levels are important to check in all patients
with altered mental status.
262.The answer is e. (Rosen, pp 1161-1162.) The patient has
hypertensive encephalopathy, which is defined by a rapid rise in BPthat
is accompanied by neurologic changes. Patients typically present with a sys-
tolic BP > 220 mm Hg and diastolic BP > 110 mm Hg. Neurologic findings
include severe headache, vomiting, drowsiness, confusion, seizure, blindness,