Altered Mental Status
Rapid Review
- Differentials
- “AEIOU-TIPS”
- Alcohol
- Electrolytes, Endocrine, Encephalopathy
- Infection
- Overdose
- Uremia
- Trauma
- Insulin
- Poisons, Psychogenic
- Stroke, Seizure, Space occupying lesion, Shock
- “AEIOU-TIPS”
- History
- Baseline mental status
- Last seen normal
- Recent trauma
- New medications/exposures
- Recent surgery/illness
- Additional symptoms
- Physical Exam
- Signs of trauma
- Consider concussion, brain bleed
- Pupil size
- Consider overdose, ICP
- Neck stiffness
- Consider meningitis
- Odor
- Consider DKA, alcohol
- Neurological deficits
- Consider stroke, seizure
- Abnormal lung sounds
- Consider pneumonia, heart failure, COPD
- Skin lesions
- Consider infection
- Signs of trauma
- Work-Up
- Labs:
- CBC, CMP, UA, blood alcohol level.
- Consider: urine drug screen, TSH, lactate, ABG, blood cultures, lumbar puncture
- Imaging:
- CXR
- Head CT
- Labs:
Pearls
Deep Dive
Headache
Rapid Review
- Differentials
- Most serious
- Meningitis
- Subarachnoid hemorrhage
- Temporal arteritis
- CVA
- Cervical artery dissection
- Venous Sinus Thrombosis
- Most Common
- Tension headache
- Migraine headache
- Sinusitis
- Most serious
- History
- Worst headache of life
- Consider dissection, CVST, SAH
- Neck stiffness
- Consider meningitis, brain abscess
- Sick contacts
- Consider carbon monoxide poisoning, meningitis
- Vertigo
- Consider stroke, vertebral artery dissection
- Confusion
- Consider encephalitis, CVST, mass
- Visual Changes?
- Consider mass, glaucoma, temporal arteritis
- Head Trauma
- Consider intracranial bleeding, concussion
- Worst headache of life
- Physical Exam
- Head trauma
- Consider intracranial bleeding, concussion
- Dilated pupil
- Consider acute glaucoma, brain injury
- Photophobia
- Consider migraine, meningitis
- Kernig/Brudzinski Sign
- Consider meningitis
- Rashes/lesions
- Consider meningitis
- Neurological deficits
- Consider cervical artery dissection, space-occupying lesion
- Head trauma
- Work-Up
- Labs
- CBC, BMP, ESR, blood cultures
- Lumbar puncture for CSF analysis
- Imaging
- Head CT w/o contrast (if suspect cerebellar stroke
- MRI brain w/o contrast (if CT negative)
- CTA of head/neck (if suspect dissection)
- Labs
Pearls
Deep Dive
Syncope
Rapid Review
- Differentials
- Cardiac
- Arrhythmias (WPW, Brugada, VF/VT, AV block)
- Aortic stenosis
- Aortic dissection
- Pulmonary embolism
- Reflex
- Vasovagal
- Carotid sinus syndrome
- Orthostatic hypotension
- Neuro
- Stroke
- Seizure
- Pulmonary
- Pulmonary embolism
- Pneumothorax
- Genitourinary
- Ectopic pregnancy
- Gastrointestinal
- Upper/lower GI bleed
- Cardiac
- History
- Head trauma before or after episode
- Consider brain hemorrhage
- Tonic/clonic movements, tongue biting, urinary incontinence
- Consider seizure
- Recent emotional stress
- Consider vasovagal syncope
- Associated with exertion
- Consider cardiac or vascular causes
- Diabetic
- Consider hypoglycemia
- Melena or hematochezia
- Consider GI bleed
- Head trauma before or after episode
- Physical Exam
- Head trauma
- Consider intracranial hemorrhage
- Murmurs, Rubs, Gallops
- Consider aortic stenosis or heart failure
- Capillary refill
- Consider dehydration
- Rales/wheezing in lung fields
- Consider heart failure
- Neurologic deficits
- Consider stroke
- Tongue bite marks
- Consider seizure
- Head trauma
- Work-Up
- EKG
- Look for ischemia, arrhythmia, delta wave, long QT, etc.
- Labs
- CBC, BMP, hCG
- Imaging
- CXR
- Head CT w/o contrast
- EKG
Pearls
Deep Dive
Dizziness
Rapid Review
- Differentials
- Vertigo
- Benign Positional Peripheral Vertigo
- Labrynthitis
- Meniere Disease
- Cerebellar stroke
- Vertebral basilar artery insufficiency
- Brain tumor
- Multiple sclerosis
- Lightheadedness
- Anemia
- Hypotension
- Bradycardia
- Dehydration
- Vertigo
- History
- What do you mean by “dizzy”
- Differentiate between vertigo and lightheadedness
- Positional
- Consider BPPV
- Palpitations
- Consider arrhythmia
- Chest pain/SOB
- Consider ACS/PE
- Focal neurologic deficits (diplopia, dysarthria, dysphagia, dystaxia)
- Consider cerebellar dysfunction
- What do you mean by “dizzy”
- Physical Exam
- Head Impulse Test
- Abnormality suggests peripheral lesion
- Nystagmus
- Horizontal/vertical/rotary nystagmus suggests central lesion
- Test for Skew
- If unable to remain focused on spot, specific for central lesion
- Head Impulse Test
- Work-Up
- EKG
- Useful for work-up of lightheadedness/pre-syncope
- Labs
- CBC, BMP, hCG
- Imaging
- CT or MRI (if concern for central lesion)
- EKG
Pearls
Seizure
Rapid Review
- Differentials
- Metabolic/Endocrine
- Hypoglycemia
- Hyperglycemia
- Hyponatremia
- Uremia
- Medications
- Antispasmodics
- Anticholinergics
- Antipsychotics
- Antibiotics (isoniazid, fluoroquinolones)
- Substance use
- Alcohol withdrawal
- Stimulants
- Organophosphates
- Infection
- Meningitis
- Encephalitis
- Brain abscess
- Structural
- Intracranial hemorrhage
- Hydrocephalus
- Neoplasm
- Metabolic/Endocrine
- History
- Type of seizure
- Differentiate between generalized vs partial
- Previous episodes
- Consider hx of epilepsy
- Head trauma
- Consider intracranial hemorrhage
- Drug/alcohol use
- Consider alcohol withdrawal or drug toxicity
- Diabetic
- Consider hypoglycemia
- Type of seizure
- Physical Exam
- Head trauma
- Consider intracranial hemorrhage
- Tongue biting
- Consider seizure vs syncopal episode
- Rashes/lesions
- Consider infectious causes
- Pregnancy
- Consider eclampsia
- Head trauma
- Work-Up
- Labs
- CBC, CMP, BAL, Urine drug screen
- Imaging
- CT head non contrast (if first seizure)
- Labs
Pearls
Physician assistant graduate from Duke University (Class of 2022). Army National Guard Medic. Former paramedic. Devoted to learning and sharing evidence-based medicine.