PEM/R+ Neuro - Altered Mental Status (AMS)

Differential diagnosis (DDx) --> Delirium What is the mnemonic for the causes of delirium? (Rosen Neuro Chapter 104; Table 104)

"I WATCH DEATH".

Perspective --> Delirium --> Subtypes What is "hypoactive delirium" sometimes referred to as? (Rosen/LITFL)

"Quiet delirium".

Empirical management --> Management algorithm Reference: Management algorithm for confusion. (Rosen Figure 17-4)

(Figure 17-4. Management algorithm for confusion.)

Approach --> Labs & Imaging What is the paradoxical thing to know about ordering a CBC for the confused patient? (Rosen)

**It is commonly ordered, but RARELY provides useful diagnostic clues, unless you suspect that the patient has profound anemia!

Organic causes of AMS (including delirium & coma) For each pathophysiologic cause, list the possible differentials (ddx): 6. Metabolic (8+)

1. Acidosis 2. INC CO2 3. DEC O2 4. Electrolyte changes 5. Hepatic encephalopathy 6. Uremia 7. Endocrine (DEC glucose, INC glucose = HHS or DKA, adrenal, thyroid INC or DEC) 8. Nutritional (Wernicke's, B12 deficiency).

Pathophysiology Conceptually, consciousness may be divided into which 2 types of elements? (Rosen)

1. Alertness or arousal, or 2. Content of consciousness.

Dementia differential (ddx) For each system, list the possible differentials: 1. Degenerative (4)

1. Alzheimer's 2. Parkinson's 3. Huntington's 4. Pick's disease.

Physical exam clues in the patient with AMS --> VS For each VS abnormality, list the possible etiologies: 1. Hyperthermia (3)

1. Infection 2. Thyroid storm 3. Adrenergic stimulation (drug overdose or withdrawal).

Dementia differential (ddx) For each system, list the possible differentials: 4. Inflammatory (2)

1. Lupus 2. Demyelinating disease.

Approach --> Physical exam You are at the bedside, ready to assess a patient's confusion. What are the 3 popular cognitive screen tests that you may initially choose to use? (Rosen)

1. MMSE 2. QCS (Quick confusion scale) 3. 6-item screener.

Rapid assessment & stabilization What are 3 measures that may be taken to prevent the confused patient from harming themselves or others? (Rosen)

1. Medication 2. Physical restraint 3. Family members, assist with observation & comfort.

Dementia differential (ddx) For each system, list the possible differentials: 3. Infectious (4)

1. Meningitis/encephalitis 2. Neurosyphilis 3. Creutzfeldt-Jakob disease 4. HIV.

Physical exam clues in the patient with AMS --> VS For each VS abnormality, list the possible etiologies: 3. Tachypnea (3)

1. Metabolic acidosis (DKA) 2. Stimulant 3. Aspirin OD.

Approach Broadly, AMS includes which types of "states"? (5)

1. Mild confusional states 2. Delirium 3. Dementia 4. Coma 5. Decompensated psychiatric syndrome.

Physical exam clues in the patient with AMS --> VS For each VS abnormality, list the possible etiologies: 4. Bradypnea (2)

1. Narcotic OD 2. CNS insult.

Organic causes of AMS (including delirium & coma) For each pathophysiologic cause, list the possible differentials (ddx): 1. Drugs/toxins (9+)

1. Opiods 2. Antipsychotics 3. Sedative-hypnotics 4. Lithium 5. Antihistamines 6. Anticholinergics 7. *Polypharmacy. 8. Drugs of abuse, withdrawal states 9. Toxins (eg, toxic alcohols, CO, cyanide, mushrooms). Pic: Poisoning syndromes/Toxidromes.

Physical exam clues in the patient with AMS --> Ocular exam Broadly, what are the categories of ocular exam findings you would expect? (4)

1. Pinpoint pupils 2. Dilated pupils 3. Asymmetric pupils 4. Papilledema.

Dementia differential (ddx) For each system, list the possible differentials: 5. Neoplastic (3)

1. Primary CNS tumor 2. Metastatic disease 3. Paraneoplastic syndromes.

Disposition What are the exceptions to admission, in which the confused patient may be d/c'ed? (2) (Rosen)

1. Pts with rapidly resolved confusional states after treatment for insulin-induced hypoglycemia, or 2. After recovery from intoxications or withdrawal states, such as those related to ethanol or recreational drugs. These patients may be observed and then discharged after successful identification & resolution of the acute confusional state. Unresolved confusion or unexplained findings on repeat mental status screening should prompt admission or careful reevaluation before consideration of discharge.

Organic causes of AMS (including delirium & coma) For each pathophysiologic cause, list the possible differentials (ddx): 3. Infectious (5)

1. Sepsis 2. Fever-related delirium 3. Occult infection (esp. in elderly: PNA, UTI, skin) 4. Meningitis/encephalitis 5. Neurosyphilis.

Physical exam clues in the patient with AMS --> VS For each VS abnormality, list the possible etiologies: 7. Hypotension (6)

1. Shock 2. Sepsis 3. Hemorrhage 4. Toxins 5. Occult trauma 6. GI bleed 7. Addisonian crisis.

Physical exam clues in the patient with AMS --> Ocular exam For each ocular exam finding, list the possible etiologies: 2. Dilated pupils (2)

1. Sympathomimetic toxidrome 2. Anticholinergic toxidrome.

Diagnostic approach What 4 groups of disorders broadly encompasses most causes of diffuse cortical dysfunction? (Rosen Box 17-1)

1. Systemic diseases secondarily affecting the CNS 2. Primary intracranial disease 3. Exogenous toxins 4. Drug withdrawal states.

Dementia differential (ddx) For each system, list the possible differentials: 6. Traumatic (3)

1. TBI 2. SDH 3. Anoxic brain injury.

Approach --> History What do you specifically look for when taking a careful history? (6)

1. Underlying disorder 2. Witness to onset 3. Time of onset (duration; when the patient "last exhibited normal thinking & behavior") 4. Circumstances surrounding AMS (recent illness) 5. Meds (recent changes; esp. cessation of benzos or EtOH) 6. Evidence of intoxication/substance use.

Physical exam clues in the patient with AMS Very very broadly, which 2 types of PE findings are you looking for?

1. VS 2. Ocular exam.

Organic causes of AMS (including delirium & coma) For each pathophysiologic cause, list the possible differentials (ddx): 2. Medication-related syndromes (3)

1. Valproic acid (hyperammonemia) 2. Serotonin syndrome 3. NMS.

Approach --> Physical exam What do you specifically look for in the physical exam? (5)

1. Vitals 2. Signs of trauma 3. Focal neurological sx 4. Pupil exam 5. Skin exam (ex: hidden butt infection!).

Approach --> Procedures Ordering an LP would give you CSF to help you clarify what 4 diagnoses? (Rosen)

1. Bacterial meningitis 2. Encephalitis 3. Aseptic meningitis 4. Subarachnoid hemorrhage.

Organic causes of AMS (including delirium & coma) For each pathophysiologic cause, list the possible differentials (ddx): 5. Trauma (5)

1. Burns 2. Electrocution 3. Systemic inflammatory response (SIRS) 4. Fat embolism 5. Occult trauma (eg, abuse, neglect).

Organic causes of AMS (including delirium & coma) For each pathophysiologic cause, list the possible differentials (ddx): 4. Neurologic (7)

1. CVA 2. Head injury (concussion, bleed, diffuse axonal injury) 3. Subarachnoid bleed 4. Seizure or post-ictal state 5. Neoplasm 6. Hypertensive encephalopathy 7. Anoxic brain injury.

Dementia differential (ddx) Broadly, what are all the systems which comprise the dementia differential? (10)

1. Degenerative 2. Vascular 3. Infectious 4. Inflammatory 5. Neoplastic 6. Traumatic 7. Toxic 8. Metabolic 9. Psychiatric 10. Hydrocephalus.

Differential diagnosis (DDx) Broadly, what are the 2 types of algorithms that may be used to assess the confused patient? (Rosen Figures 17-3 & 17-4)

1. Diagnostic algorithm 2. Management algorithm.

Approach --> Physical exam Your patient is so zonked that you can't perform the MMSE, QCS, or do the 6-item screener, ie, perform a detailed cognitive screening test for attention. At this point, what 3 methods may you use alternatively as a very, very brief screen for attention function? (Rosen)

1. Digit repetition forward (5-6 digits) & backward (4 digits) 2. Spelling a commonly used word backward ("world"). Measures concentration. 3. "Sweet 16" test. Recently described in 2010. Has been studied in patients in the post-hospitalization period.

Organic causes of AMS (including delirium & coma) Very broadly, the pathophysiological causes of AMS fall under which categories? (6)

1. Drugs/toxins 2. Medication-related 3. Infectious 4. Neurologic 5. Trauma 6. Metabolic.

Physical exam clues in the patient with AMS --> VS For each VS abnormality, list the possible etiologies: 2. Hypothermia (3)

1. Environmental 2. Hypothyroidism 3. Sepsis.

Approach --> History Who are the most useful sources of information? (2) (Rosen)

1. Family members 2. Physician or other caregiver with an established relationship with pt.

Physical exam clues in the patient with AMS --> VS For each VS abnormality, list the possible etiologies: 5. Tachycardia (6+)

1. Fever 2. Sepsis 3. Dehydration 4. Thyroid storm 5. OD (stimulant, TCA, Aspirin, Theophylline, anticholinergic) 6. Acidosis.

Physical exam clues in the patient with AMS --> VS For each VS abnormality, list the possible etiologies: 6. HTN (5)

1. HTN emergency 2. Pre-eclampsia 3. Pain 4. Adrenergic stimulation (drug ingestion or withdrawal) 5. INC ICP.

Approach --> Physical exam What are the components of the "Sweet 16 Cognitive Assessment Tool"? What specifically are its 2 benefits over using the MMSE? (Medscape)

1. Higher sensitivity 2. Quicker to administer (2 min vs. 10 min for the MMSE).

Perspective --> Delirium --> Subtypes What are the subtypes of delirium? (3) (Rosen/LITFL)

1. Hyperactive 2. Hypoactive 3. Mixed.

Physical exam clues in the patient with AMS --> VS What are some examples of VS changes that would be relevant to the diagnosis of AMS? (8)

1. Hyperthermia 2. Hypothermia 3. Tachypnea 4. Bradypnea 5. Tachycardia 6. Bradycardia 7. HTN 8. Hypotension.

Rapid assessment & stabilization Most patients with acute confusion do not require immediate interventions. But what are the 3 crucial exceptions? (Rosen)

1. Hypoglycemia 2. Hypoxemia 3. Shock.

Differential diagnosis (DDx) --> Critical vs. Emergent diagnoses What are some examples of CRITICAL confusion diagnoses? (5++) (Rosen Box 17-3; NOT an exhaustive list)

1. Hypoxia; diffuse cerebral ischemia - Respiratory failure - Congestive heart failure (CHF) - Myocardial infarction (MI) - Shock 2. Systemic process - Hypoglycemia 3. CNS infections 4. Hypertensive encephalopathy 5. Elevated ICP--medical & surgical origin.

Differential diagnosis (DDx) --> Critical vs. Emergent diagnoses What are some examples of EMERGENT confusion diagnoses? (5+++) (Rosen Box 17-3; NOT an exhaustive list)

1. Hypoxia; diffuse cerebral ischemia - Severe anemia 2. Systemic diseases - Electrolyte & fluid disturbance - Endocrine disease: Thyroid, Adrenal - Hepatic failure - Nutrition, Wernicke's encephalopathy - Sepsis, Infection 3. Intoxications & Withdrawal - CNS sedatives - EtOH - Other med side effects, particularly anticholinergics 4. CNS disease - Trauma - Infections - Stroke - Subarachnoid hemorrhage (SAH) - Epilepsy, Seizures: Postictal state, Nonconvulsive status epilepticus, Complex partial status epilepticus 5. Neoplasm.

Delirium --> Pearl Under which circumstances is an organic etiology (ie, as opposed to functional/psychiatric) for delirium more likely? (4)

1. If age < 12 or > 40 2. Having visual hallucinations (as opposed to auditory) 3. Acute onset 4. Any abnormal exam!

Epidemiology Confusion is estimated to occur in __% of ED patients, __% of all hospitalized patients, and __% of elderly hospitalized patients. (Rosen)

2%, 10%, 50%.

Differential diagnosis (DDx) --> Diagnostic algorithm Placement of AMS into 1 of 3 categories may help guide the differential assessment and therapy. What are the 3 categories? (Rosen Figure 17-3)

3 AMS categories, for diagnostic purposes: 1. Diminished level of consciousness 2. Acute focal neurological deficit 3. Abnormal attention span. (Figure 17-3. Diagnostic algorithm for confusion.)

Diagnostic approach Likewise, what does subcortical or brainstem dysfunction most frequently result in? (Rosen)

A diminished level of alertness and consciousness, NOT confusion.

Perspective --> Delirium What is the definition of "delirium"? (LITFL)

A disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time and fluctuates over time (DSM IV).

Approach What immediate steps do you take for a patient who is unconscious or severely altered? (3+) (PEM/Rosen)

ABCs VS (complete set, including TEMP & O2 sat for hypoxia) "Coma cocktail": - Bedside glucose measurement OR give 1 amp D50W - Narcan (Naloxone) 0.4-2 mg IV or IM, Thiamine 100 mg.

Delirium What is the definition of "delirium"?

Acute state of temporary or fluctuating disturbance of consciousness (eg, impaired cognition, perception disturbances, reduced attention, hypo- or hyperactivity) that is caused by an organic medical condition or medication/drug (ie, *not psychiatric).

Approach Uh oh. What do you do if the cause of confusion still remains unclear or if the patient is unable to function safely in his or her current environment? (Rosen)

Admission. Esp. to perform additional ongoing assessment, including diagnostic testing not usually available in the ED, such as MRI or EEG.

Approach --> Labs & Imaging In what circumstances in an ABG indicated for the confused patient? (Rosen)

Almost NEVER, unless the pulse ox isn't working.

Perspective --> Delirium --> Subtypes What is meant by "hyperactive delirium"? (Rosen/LITFL)

An acute confusional state associated with increased alertness, increased psychomotor activity, and disorientation and is often accompanied by hallucinations.

Approach --> Physical exam The tasks measured by either the MMSE or the QCS require adequate _______ on the part of the patient. (Rosen)

Attention.

Approach --> History How to hallucinations usually manifest in the case of delirium (vs. psychiatric)? (Rosen)

Hallucinations in delirium tend to be visual (with or without auditory components), powerful, fleeting, and poorly organized.

Dementia What is (another) definition of "dementia"?

Chronic, steady decline in short- & eventual long-term memory.

Perspective --> Confusion What is the definition of "confusion"? (Rosen)

Connotes an alteration in higher cerebral functions, such as memory, attention, or awareness. The ability to focus and sustain attention is impaired. It is a symptom, not a diagnosis. The degree of confusion may fluctuate with their level of consciousness.

Perspective --> Delirium --> Subtypes How may a patient act when in a state of "hyperactive delirium"? (Medicopedia)

He or she may become physically aggressive at any moment, and become dangerous to other patients and staff. They can become extremely agitated, yell, call out for help, wander the hallways, enter other patient's rooms (although this commonly occurs in more advanced stages of dementia also). You may observe a rapid change of behavior from docile to agitated and violent.

Approach --> Labs & Imaging What do you order for evaluation? (8 +/- 4) What would you be specifically looking for with each test? (PEM/Rosen)

ED basic testing: *1. CBC *2. Chem 10 (esp. Na+) *3. UA (UTI) *4. CXR (PNA) *5. EKG (MI may manifest atypically as confusion) ED advanced testing or consultation: 6. LFTs (hepatic encephalopathy) 7. TSH 8. Tox screen ED "second tier" testing or consultation: 9-13. CO, NH3, Ca2+, Head CT, LP, ABG, cultures, MRI, EEG.

Physical exam clues in the patient with AMS --> Ocular exam For each ocular exam finding, list the possible etiologies: 4. Papilledema (1)

INC ICP.

Epidemiology True or false: Delirium in older ED patients was not found to be an independent predictor of increased mortality within 6 months. (Rosen)

False.

Rapid assessment & stabilization A confused patient with acute pulmonary edema, hypoxia, and confusion obviously requires evaluation for what, and not what? (Rosen)

For pulmonary edema, NOT a screening test for cognitive functioning!

Approach --> Procedures When would it be appropriate to order a paracentesis or thoracentesis? (Rosen)

If ascites or pleural effusion is present.

Rapid assessment & stabilization You have a confused patient and are trying to determine if there is an organic vs. functional (psychiatric) cause. What will a schizophrenic patients physical exam findings look like? What is the meaning of "psychosis"? (Rosen)

In general, in patients with schizophrenia and other psychiatric disorders, results of tests of cognition, orientation, and attention are normal unless the condition is severe. The term "psychosis" implies a disorder of reality testing and thought organization severe enough to interfere with normal daily functioning. Psychosis is a nonspecific syndrome, and careful evaluation is required to differentiate between psychiatric and organic origins (e.g., drug intoxication or other systemic process).

Perspective --> Delirium --> Subtypes Describe how the patient appears in a state of "hypoactive delirium". (Medicopedia)

In hypoactive delirium, the patient will often appear sluggish and lethargic, to the point of stupor. Like hyperactive delirium, the onset is sudden, and there is the distinguishing feature of fluctuating level of consciousness. The patient is often perceived to be depressed by non-psychiatric physicians and nurses. Psychiatric consultation is often requested to treat the patient for depression.

Perspective --> Delirium What is the hallmark and most pivotal feature of delirium? (LITFL)

Inattention.

Approach --> Physical exam For each physical exam finding, describe the cause of confusion that it may suggest, and what you may subsequently order. Fever? (Rosen)

Infection. Search for the source, ie, PNA or UTI. CBC -- Whites CXR -- PNA UA -- UTI.

Physical exam clues in the patient with AMS --> Ocular exam For each ocular exam finding, list the possible etiologies: 3. Asymmetric pupils (1)

Intracranial process with mass effect or herniation.

Perspective --> Delirium --> Subtypes What is the treatment for "hypoactive delirium"? (Medicopedia)

It consists mostly of environmental, or supportive, care. The most challenging of symptoms in hypoactive delirium is the switch in the day-night cycle that is very common. Care is taken to assure that as much light as is practical is provided during daylight hours, and that the room is kept dark and as quiet as possible during nighttime hours. Often, these patients will require pharmacological "encouragement" to correct this disturbance. This would be, again, lorazepam, administered in very small doses to promote sleep. Of course, blood clots must be prevented, and a combination of therapies may be provided, including low-molecular weight heparin (Enoxaparin) or SCDs (these are worn on the legs and deliver a mild compressive force similar to peristalsis). To prevent bedsores, diligent surveillance is required for all surfaces of the body that have prolonged contact with the surface of the bed. Patients are "turned" at frequent intervals so that no one area of the body is in constant contact with the bed.

Approach --> Physical exam What is the utility & what are the components of the "6-item screen"? (Rosen/UpToDate)

It has similar performance against the MMSE.

Pathophysiology The pathophys of confusion is not clearly understood, however, what is the basis for claiming that it is likely due to "widespread cortical dysfunction"? (Rosen)

It's though to result from substrate deficiencies (hypoglycemia or hypoxemia), neurotransmitter dysfunction, or circulatory dysfunction. Compounding this problem is the concept that the reserve of CNS function varies from individual to individual; individuals with a preexisting impairment may become confused after even MINOR changes in their normal physiologic state.

Perspective --> Delirium --> Subtypes What is meant by "mixed delirium"? How is it treated? (Medicopedia)

Mixed delirium is, to be blunt, "double trouble." This is because you have a combination of hypoactive and hyperactive types, and you never know when the patient will change from one to the other. These patients are the most challenging of the three types. All of the above mentioned interventions are administered, and of course, these patients require the closest surveillance.

Dementia differential (ddx) For each system, list the possible differentials: 2. Vascular (1)

Multi-infarct dementia.

Diagnostic approach Does focal cortical dysfunction, such as from tumor or stroke, typically cause confusion? In such cases, what may be mistaken for confusion? (Rosen)

No. Occasionally, receptive or expressive dysphasia may be mistaken for confusion.

Pivotal Findings How useful are lab findings & diagnostic imaging in working up a confused patient? (Rosen)

Not that useful, especially as compared to the previous 3 methods.

Perspective --> Delirium --> Subtypes For a psych perspective, what are the treatment options (and dosing) for patients with "hyperactive delirium"? (Medicopedia/Rosen)

One way we treat patients afflicted with delirium is with a mild sedative and sometimes, haloperidol. The most commonly used sedative is lorazepam, a benzodiazepine, and it simply keeps the patient calm. A typical dose of lorazepam is **0.25 to 0.5 mg every four to six hours prn (as needed) for agitation. Haloperidol is an antipsychotic, which in very small doses is used once the patient is observed becoming agitated, combative, etc. It works very quickly, as does lorazepam, but is more effective than lorazepam for treating the behavioral dyscontrol. A common dose of haloperidol used is **0.25 - 0.50 mg every four to six hours prn for severe agitation/acute psychosis. Rosen: Benzos, butyrophenones (the "dols", ex: haldol), or newer antipsychotic meds may be used if necessary to dec agitation, but any of these might confound evaluation of the confusional state!

Physical exam clues in the patient with AMS --> Ocular exam For each ocular exam finding, list the possible etiologies: 1. Pinpoint pupils (1)

Opioid ingestion.

Approach --> Physical exam For each physical exam finding, describe the cause of confusion that it may suggest: New focal neurological deficit? (Rosen)

Possible mass lesion or stroke, but these would manifest with confusion ONLY if global cortical dysfunction was caused by surrounding cerebral edema or elevated ICP by severe mass effect. In this regard, testing of gait and tandem gait, if possible, may be invaluable. Aphasia, fluent or non-fluent, is a focal sign suggesting a lesion in the dominant cerebral hemisphere.

Differential diagnosis (DDx) --> Emergent diagnoses Describe how a patient would be expected to present differently between: 1) postictal state, vs. 2) non-convulsive status epilepticus. (Rosen)

Postictal confusion is common in patients with seizures but should improve within 20 to 30 min. If the patient remains unconscious or confused after a seizure, the possibility of ongoing or intermittent seizure activity (i.e., nonconvulsive seizures) should be considered. Nonconvulsive status epilepticus, an epileptic twilight state, is unusual but does occur and may be particularly difficult to recognize in the elderly.

Delirium vs. Dementia What is the definition of "dementia"?

Progressive, unremitting decline in cognitive function.

Approach --> Physical exam What is the utility of using a cognitive screen test? (Rosen)

Screening tests may detect confusion NOT obvious in casual conversation, identifying the need for further investigations.

Approach --> Physical exam What is the reality about using the Mini-Mental Status Exam (MMSE), and what is commonly used instead? (Rosen)

The MMSE is commonly is recommended as a screening instrument but is used infrequently in the ED because of the time required for administration. A more rapidly performed screening tool, the Quick Confusion Scale (QCS), has been developed and tested in ED patients.

Perspective --> Delirium --> Subtypes What is meant by "hypoactive delirium"? (Rosen/LITFL)

The confusional state is present but the patient has a reduction in alertness and behavior. Hypoactive delirium may be the more common type in ED patients.

Perspective --> Delirium --> Subtypes Describe what consequences may be expected with a patient is in a state of "hypoactive delirium". (Medicopedia)

The hypoactive form is the least recognized of the deliria. The patient is calm, not causing any disturbance on the medical floor, and thus, has the highest mortality rate of the three types of delirium. Mortality usually occurs secondary to pulmonary emboli in the elderly. This occurs simply because the patient is not causing a lot a problems, and therefore is not monitored as closely as he or she should be, when they remain on the medical unit, such that they often remain lying in bed. This predisposes them to 1) bedsores which can very quickly lead to devastating infection, as well as 2) DVT which produces PE.

Disposition How are most patients with a presenting sign of confusion handled? (Rosen)

They're admitted or go to ED obs unit.

Approach --> Physical exam Explain the utility & components of the Quick/Rapid Confusion Scale (QCS). (Rosen)

This tool objectively measures elements of the patient's mental status in 2 to 3 minutes and correlates well with the MMSE.

Pivotal Findings What are the 3 main ways a patient with AMS, including confusion, in evaluated? (Rosen)

Through: 1. Focused history & PE 2. Rapid beside screening tests 3. Response to certain therapies (eg, dextrose or naloxone).

Approach --> Labs & Imaging When is a Head CT usually performed for the confused patient? (Rosen)

To screen for CNS lesions in the absence of another identified source of the confusion.

Dementia What may a stuttering course point to?

Vascular (multi-infarct) dementia due to lacunar infarcts.

Epidemiology When is "confusion" most likely to receive full and immediate consideration by the ED clinician? (Rosen)

When confusion exists as an isolated or unexplained finding. Often, confusion is accepted as an incidental or secondary component of another condition. A patient with injuries from a motor vehicle crash or with dyspnea may be confused, but the primary condition overshadows the underlying abnormal mental status.

Approach --> Physical exam --> Fever When should you order Blood Cx and Urine Cx for the confused, febrile patient? (Rosen)

When hospital admission is anticipated & a clear infectious source is NOT evident.