Altered Mental Status

Trauma, Hyper/hypothermia, Hyper/hypocarbia, Hypoxia, SIRS/Sepsis, Metabolic encephalopathies, Metabolic derangements, ACS/MI, Arrhythmias, Stroke/TIA, Seizures, SIRS/Sepsis, Toxidromes (Intoxication/Withdrawal), Myxedema coma, Thyroid storm, Psychosis/Depression/Mania.

• No obvious signs of external trauma. Less concern for hypothermia or heat stroke given normal temperature. Sufficient respiratory rate and SpO2 > 90 on RA, less concerning for hyper/hypocarbia or hypoxia. Blood pressure and clinical presentation not consistent with hypertensive encephalopathy. Patient is afebrile, without concerning acute infectious symptoms, less likely an infectious source or SIRS/Sepsis as a cause of the patient's presentation.
  
  

• No clinically significant electrolyte or blood glucose abnormalities which could be responsible for the patient's presentation.
  
  

• Patient's presentation not consistent with cardiogenic causes given negative troponin and no arrhythmias or acute ischemic changes noted on EKG.
  
  

• Given no adventitous breathsounds, sufficient RR and SpO2, and no history of pulmonary disease, pulmonary causes less likely causing the patient's presentation.
  
  

• Patient without history of hepatic disease or alcohol use disorder, labs results and clinical presentation not consistent with hepatic encephalopathy.

  • Given the patient's history of significant alcohol use and gradual symptom progression, would need further assessment to evaluate for Wernicke's/Wernicke-Korsasoff Syndrome
    
    

• Patient without history of renal disease, labs results and clinical presentation not consistent with uremic encephalopathy.
  
  

• Patient without any focal neurological deficits on exam, no new weakness or paresthesia on history, which are not consistent with an acute stroke/TIA.There was no evidence or reports of loss of urine, tongue lacerations, or seizure like activities, to suggest seizures/postictal state as the cause of the patient's altered mental status.

  • Given limited patient cooperation, unable to perform a neurological examination. 

  • I was able to perform a partial neurological examination, with abnormal findings with difficulty assessing if it is due to patient non-cooperation versus acute changes.

  • At this point, I suspect a possible intoxication with *** as a possible cause of the patient's altered mental status. 

    • I will treat patient symptomatically for the suspected intoxication. If the patient does not improve, I will consider imaging to rule out intracranial pathologies.

    • While I treat patient symptomatically for the suspected intoxication, I will order imaging to rule out intracranial pathologies.
      
      

• Given the patient's clinical findings, I am less concerned for an endocrine/metabolic or psychiatric causes at this point.

Patient has documented prior history of opioid use disorder. Patient reported to use ***. Patient [did not/did] require respiratory support in the form of [adjunct]. Ordered relevant labs and/or imaging. Will treat patient symptomatically.

Always Order: CBC, CMP, Troponin, bHCG*|| CXR, EKG
- CBC to check for infection, CMP to check for electrolytes and liver function, troponin for myocardial injury
- CXR because naloxone can cause pulmonary edema, EKG to assess for arrhythmias
Depends Order: VBG, Mg, CK, UA, UDS, CK, APAP, Salicyclate Level, TSH || CT Head

Differential diagnosis considered, but not limited to: Toxidromes (Intoxication/Withdrawal), Co-ingestions, Trauma, Hyper/hypothermia, Hyper/hypocarbia, Hypoxia, Encephalopathy, SIRS/Sepsis, Metabolic derangements, ACS/MI, Arrythmias, Stroke/TIA, Seizures

Physical exam consistent with possible opioid intoxication. Patient [did not/did] receive naloxone, which subsequently showed improvement in the patient's clinical status. COWS [***]

No obvious signs of external trauma. Less concern for hypothermia or heat stroke given normal temperature. Sufficient respiratory rate and SpO2 > 90% on RA, less concerning for hyper/hypocarbia or hypoxia. Blood pressure and clinical presentation not consistent with hypertensive encephalopathy. Patient is afebrile, without concerning acute infectious symptoms and no clinically concerning signs of erythema/cellulitis, less likely an infectious source or SIRS/Sepsis. No clinically significant electrolyte or blood glucose abnormalities. Patient's presentation not consistent with ACS/MI given negative troponin and no arrhythmias or acute ischemic changes or acute T-wave inversion noted on EKG. Co-ingestants also negative.

At this point, I suspect a possible intoxication with *** as a possible cause of the patient's altered mental status. There was no evidence or reports of loss of urine, tongue lacerations, or seizure like activities, to suggest seizures/postictal state.

• • • Patient without any focal neurological deficits on exam, no new weakness or paresthesia on history, which are not consistent with an acute stroke/TIA.

      • Given limited patient cooperation, unable to perform a neurological examination. 

      • I was able to perform a partial neurological examination, with abnormal findings with difficulty assessing if it is due to patient non-cooperation versus acute changes.

    • I will treat patient symptomatically for the suspected intoxication. If the patient does not continue to improve, I will consider imaging to rule out intracranial pathologies.

    • While I treat patient symptomatically for the suspected intoxication, I will order imaging to rule out intracranial pathologies.

DISPOSITION: ADMISSION
The patient was observed in the Emergency Department for *** hours without recurrence of any respiratory compromise. At the time for discharge, patient is awake, able to ambulate, tolerating oral intake, and maintaining normal oxygen saturation without supplementation. Patient is clinically sober ans safe for discharge. The patient was offered referral and transfer to addiction treatment/rehabilitation services, including medication-assisted treatment when appropriate. A prescription for naloxone was offered, and the patient received counseling on overdose prevention, avoiding opioid use while alone, avoiding co-use with alcohol or benzodiazepines, and the importance of seeking treatment for opioid use disorder. Strict return precautions were discussed, including recurrent sedation, difficulty breathing, chest pain, confusion, vomiting, or any other worsening symptoms.

DISPOSITION: ADMISSION
The current presentation is concerning for ***. Given the patient's clinical presentation, diagnostic findings, and need for continued monitoring, treatment, and further diagnostic evaluation, the patient is not appropriate for discharge from the ED. Case discussed with ***, who accepts the patient for admission.