Altered Mental Status
Answers
247.The answer is c.(Rosen, pp 1748-1750.)The patient never received
afingerstick glucoseat triage. Hypoglycemiacan mimic a cerebrovas-
cular accident or seizure. Therefore, it is critical that all patients who present
with altered mental status get fingerstick glucose. Glucose level should be
considered a vital sign. Hypoglycemia is a common problem in patients
with type 1 diabetes. The clinical presentation of hypoglycemia is caused by
increased secretion of epinephrine, as well as central nervous system (CNS)
dysfunction. Symptoms include diaphoresis, nervousness, tremor, tachycar-
dia, hunger, and neurologic symptoms ranging from confusion and bizarre
behavior to seizures and coma.
(a)Ethanol withdrawal can present in a similar fashion as hypoglycemia
since both include symptoms of an adrenergic state (eg, tachycardia, hyper-
tension, diaphoresis, agitation). Even if you suspect ethanol withdrawal, it is
mandatory to check fingerstick glucose. (b)The stroke team should be acti-
vated in patients who present with signs and symptoms of a stroke that are
not caused by hypoglycemia. Therefore, these patients need a fingerstick
glucose.(d)Sundowning refers to people who become increasingly confused
at the end of the day and into the night. Sundowning isn’t a disease, but a
symptom that often occurs in people with dementia, such as Alzheimer dis-
ease. It is more commonly observed on the hospital wards than in the ED.
(e)Haloperidol is commonly used as a sedative for agitated patients. However,
this patient is agitated because of an organic cause, hypoglycemia. By treating
the underlying cause (administering glucose), the agitation will resolve.
248.The answer is d.(Tintinalli, p 1314.)Myxedema comais a life-
threateningcomplication of hypothyroidism.Mortality in myxedema coma
approaches 20% to 50% even with appropriate management. The patient
exhibits classic signs and symptoms of the disease: lethargy or coma, hypother-
mia, bradycardia, periorbital and nonpitting edema, and a delayed relaxation
phase of deep tendon reflexes (areflexia in more severe cases). Myxedema coma
can be triggered by sepsis, trauma, surgery, congestive heart failure, prolonged
cold exposure, or use of sedatives or narcotics (as seen in this example).
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