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If the studies are within normal limits, much has been done to rule out an acute medical condition. But let’s say you have all the time and all the money in the world. You say, “Look, we’ve done all this acute stuff, we said they are not going to die in the next hour, what do we do now?” I’m the only neurologist in town, there is no psychiatrist, I’ve got to pretty much do everything myself, what do I do? Consider an MRI to detect a CNS lesion. Consider a EEG. Sometimes subtle forms of seizures, as you know, can present with confusion. These second tier of laboratory studies, things they probably wouldn’t do in an ER but might do on a psychiatric unit; iron, magnesium, B12, folate, thyroid panel and VDRL. Then if you want to rule out everything in the world – say you’ve got a 20-year-old. He comes in, he’s confused. You’ve done all this stuff and you are probably thinking at this point, what? You’ve done all these studies and everything is negative and this kid is still confused, what do you think it probably is? Probably schizophrenia. You’ve probably got a kid who has got an underlying psychiatric condition. But what you want to do in a 20-year-old is you want to spend every last dollar before you say, oh this is schizophrenia and let’s treat it like schizophrenia. Because every psychiatrist’s worst nightmare is treating some kid for schizophrenia for five years and then seeing one day a Kayser-Fleischer ring. Oops. The kid had Wilson’s disease all along. So the “every-last-dollar-workup” is you want to get a serum ceruloplasmin and there are some other things with the Wilson’s workup. ESR, ANA and heavy metal screening.
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Treatment of confusion. Number one treat the underlying cause, then treat agitation if present.
The confused alcoholic. Keep the patient in the hospital if withdrawal is suspected. If there is a question of what to do with this alcoholic and he seems confused, his blood alcohol level has returned to normal, so it’s not just drunkenness and he doesn’t seem drunk. Confusion isn’t the same as drunkenness. They don’t know where they are, they don’t know what year it is, they are confused. Don’t send that alcoholic home because you are risking DTs, seizures and DTs. Once you see confusion, unfortunately, you may be heading into the DTs and once you head into the DTs there’s no going back. So if you keep them in the hospital, even if they are just drunk and not confused, you’ve got to prophylax for the DTs. So let’s say you keep the person in the hospital because you think they are confused, you think they might be a DT risk, put them on seizure precaution. Because they might seize, of course. Give them thiamin. A reasonable order is 100 mg IM times three, then 100 mg PO per day for the rest of the hospitalization. Give one multivitamin per day and PO folic acid. That’s a common order. Give benzodiazepine, typically chlordiazepoxide or lorazepam.
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