Altered Mental Status Answers 295etiology of this patient’s symptoms is in the history that she gives. She tells
you that she has not taken her antiseizure medicationsin 2 days. Also,
given her evolving mental status and improvement in alertness, this patient
most likely presented in a postictal state after she has seized. Without any
focal deficit and further improvement in her mental status, one might be
comfortable with this diagnosis. Serum testing of her antiepileptic drug
levels must be performed to further investigate this suspicion. A CT of the
head, ECG, and further investigation is warranted if these levels are normal
and do not explain her loss of consciousness.
Other neurological causes, such as a cerebral vascular accident (CVA)
(a)and transient ischemic attack (TIA) (b)should also be in the differential.
Typical TIA symptoms include any neurological symptom, which improves
within 30 minutes. In this case, however, the patient’s history and presenta-
tion most likely precludes this diagnosis. The possibility of her having a
stroke is further diminished by her normal neurological examination. This
patient did not complain of any chest or abdominal symptoms (d and e),
which place aortic dissection and pulmonary embolus further down on the
differential list.