Announcements: Neuromuscular section updated with more questions.


  • Onset
  • Any precipitating factor
  • Baseline level of functioning (history of dementia?)
  • Recent infectious symptoms (dysuria, diarrhea / vomiting, URI symptoms)
  • Symptoms to suggest CNS infection (neck stiffness, headache, nausea)
  • Access to toxic ingestion / illicit substances
  • Associated focal deficits or abnormal movements
  • EtOH history

 EXAM: full general exam with attention to signs of intoxication, dehydration and infection, neurologic exam including MMSE and paying close attention to level of consciousness, focus / concentration, focal neurologic deficits; also check and document meningeal signs, asterixis and look for subtle signs of seizure

 WORKUP: determined by above but typically includes

  • Fingerstick, Chem-7, Ca/Mg/Phos, BUN/Cr, LFTs, ammonia level, TSH, RPR, B12
  • Tox screen and alcohol level
  • Carefully review medication list for medications that can cause AMS
  • UA / UCx, CXR
  • Non-contrast head CT
  • +/- LP if fever / white count of unknown source, meningeal signs / symptoms, concern for HSV limbic encephalitis
  • EEG to r/o non-convulsive status and assess degree of encephalopathy


  • Determine and treat underlying cause, often multifactorial
  • Can consider IV thiamine empirically if malnourished or EtOH history
  • Supportive measures in acute delirium:  reorienting (clocks, calendars), familiar staff / family if possible, encourage sleep-wake cycles, visual and hearing aids if visually / hearing impaired

Differential of altered mental status:

  • Drugs
  • Endocrine, Electrolytes, Ethanol, Emotional, Eyes/Ears
  • Low O2, Lack of drugs, Liver
  • Infection
  • Retention
  • Intracranial (stroke/hemorrhage/mass), Ictal
  • Uremia, Under-nutrition, Under-hydration
  • Metabolic
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