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When the psychiatrist is called to the emergency room because the patient is confused; somebody who is not acting their normal self the treatment should quickly rule out the potentially lethal and continue or refer their workup as appropriate for their subacute or sublethal condition. The patient can’t tell you what’s going on. They are having confusion, so you need somebody else to tell you, to give you part of the history. Elderly people are more apt to become confused with less of a medical insult. People, when they get older, don’t have the reserve that young people do and as a result a small medical insult will cause major mental status changes. What if you or I have a urinary tract infection? An elderly person with a urinary tract infection, their presenting complaint might be hiding themselves in their bedroom and closing the shades because they think the police are going to come and get them. So they can have mental status changes as the chief complaint in a mild pneumonia or a mild urinary tract infection.
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Another question: any psychiatric or substance abuse history? I think that’s pretty much self-explanatory. Quick review of systems. Any problem with head trauma, seizures or HIV risk? Then this is important; has there been a loss of alertness recently? Is this a new delirium or a chronic dementia? And we’ll talk about delirium versus dementia later in the day. Emergency rule-outs, kind of the quick things you want to go through. Wernicke’s encephalopathy. What do we see with Wernicke’s? Ataxia, sixth nerve palsy and confusion. That’s kind of the classic triad. Alcohol/sedative withdrawal. Hypertensive encephalopathy. What do we see with that? Papilledema, increased CSF pressure. But remember, hypertensive encephalopathy sometimes can be kind of chronic and you see this sort of mild personality stuff develop over time. Hypoglycemia. Is their blood sugar real low? Do they have a tremor? Are they dizzy? Hypoperfusion kind of goes along with hypoxemia. They are not perfusing well enough and that’s why they are confused. CNS bleed, meningitis or encephalitis. What do we see with meningitis? Stiff neck, photophobia, headache. And then acute and toxic metabolic causes and that list can be endless in and of itself.
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Initial workup of the confused patient: first, you assume there is a serious medical condition. You say, okay, there is something medically wrong with this person that needs to be reversed. Then when you have done that, you say, okay, it’s a functional problem. Call the psychiatrist. Functional is the word we use to describe not due to a medical condition. Although you may not find the cause of the confusion, and often you don’t, you want to at least rule out the potentially lethal conditions listed above. The physical exam is going to have a neurological focus, which is good because you are all neurologists. Initial diagnostic studies: chemistry profile, including electrolyte, CBC, U/A, EKG, also consider blood gas and pulse oximetry. Sometimes you want drug screening, depending on the circumstances. Obviously if they are older and in a nursing home you are probably not going to need that, but if they are a young person coming into the ER you definitely are going to need it. You want levels of commonly toxic medications like digoxin, anticonvulsants, such as Dilantin, lithium. Depending on the circumstances, you are going to want a CT scan. Sometimes a spinal tap, depending. Particularly if you are thinking something like meningitis.
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