Altered Mental Status Answers 281(a)It is critical that fingerstick glucose is checked. However, myxedema
coma differs from the early stages of hypoglycemia in that myxedema coma
results in the progressive slowing of all bodily functions; by contrast, in early
hypoglycemia, the body is stimulated by the release of adrenergic hormones.
(b)The classic findings in opioid toxicity include miotic pupils and respira-
tory depression. (c)Stroke should be on the differential in this case, but the
patient’s signs and symptoms are more consistent with an abnormal meta-
bolic state than with purely neurovascular change. Depression (e)is an often
forgotten diagnosis in the elderly and may present with a wide variety of
signs and symptoms. Severe depression may appear as lethargy. It is unlikely,
however, to have associated hypothermia and abnormal reflexes.
249.The answer is e.(Roberts and Hedges, pp 19-24.)Patients frequently
present to the ED with agitation. It is important to discern what is causing
their agitation; the range of etiologies is expansive, from ethanol intoxication
to intracerebral bleeding. The approach to the emergency patient always begins
with the ABCs (airway, breathing, and circulation).In addition, the vital
signsmust be obtained early in a patient’s assessment in order to reveal poten-
tially life-threatening conditions.The patient in the vignette presents with
agitation and tachycardia. Although it is tempting to attribute his agitation to
his untreated schizophrenia, doing this without investigating medical causes of
agitation can be disastrous. Finding out that the patient’s temperature is
103.1°F, for instance, will lead you down a different clinical path than if his tem-
perature is 98°F. This patient was ultimately diagnosed with meningitis.
(a)Administering a medication to control agitation or psychotic behav-
ior is appropriate even when there are coexistent medical problems. Patients
that are too agitated cannot be properly examined. However, it is critical to
rule out potential life threats that may be causing the agitation. (b)A psychi-
atry consultation should be obtained once life-threatening conditions are
excluded or in the case of the patient above, when he is stable and commu-
nicative as an inpatient. (c and d)A head CT and blood work will need to be
obtained in this patient; however, all of the vital signs should be obtained first.
250.The answer is a.(Tintinalli, p 1412.)The initial approach to a seizing
patient should involve protecting the patient from injury. Seizing patients
should be immediately placed in a lateral decubitus position to prevent
aspiration of gastric contents.Other initial measures are oxygen adminis-
tration, pulse oxymetry, glucose level determination, and an IV line.