Evaluation of altered mental status

acute changes in mental status likely; associated with neurologic symptoms: unilateral weakness or numbness; change in vision (unilateral or bilateral); difficulty with speech, comprehension; loss of coordination, difficulty walking; severe headache, anosognosia, neglect syndromes[48]Powers WJ, Rabinstein AA, Ackerson T, et al; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49(3):e46-110. https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000158?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed http://www.ncbi.nlm.nih.gov/pubmed/29367334?tool=bestpractice.com

confusion frequently noted; focal neurologic signs include: unilateral hemiparesis, hemianopia, aphasia, ataxia[48]Powers WJ, Rabinstein AA, Ackerson T, et al; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49(3):e46-110. https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000158?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed http://www.ncbi.nlm.nih.gov/pubmed/29367334?tool=bestpractice.com

history of trauma, often accompanied by change in level of consciousness or headache and dizziness

external evidence of trauma: bruising, bleeding, raccoon eyes, fractures, watery nasal discharge (cerebrospinal fluid rhinorrhea)

insidious, chronic decline in both memory and at least 1 other cognitive domain (executive function, language, visual-spatial) that interferes with daily life

disorientation to person, place, or time and possibly otherwise normal; suggestive score on mini-mental exam

acute, fluctuating change in mental status; underlying cognitive impairment; advanced age, recent surgical intervention, underlying infection; may accompany hip fracture

characterized by inattention, disorganized thinking, and altered levels of consciousness on neurologic exam; may have hip or pelvic tenderness with manipulation of joint

loss of consciousness, observed seizure activity, urinary incontinence, tongue trauma, may report premonitory symptoms or signs

observed tonic-clonic seizure or abnormal movements followed by drowsiness

history of risk factors for coronary artery disease (CAD) (e.g., of smoking, hyperlipidemia, diabetes, family history of CAD); chest pain (often described as heavy, or tight) radiating to arms, back, neck, or jaw; chest pain may be absent in older adults and people with diabetes; dyspnea; nausea; diaphoresis

hypotension; diaphoretic appearance; pallor; tachycardia; bradycardia; new abnormal pulse rhythm; distended jugular veins; other signs of heart failure (e.g, dyspnea, crackles at lung bases); new heart murmur; delirium is often the only identifiable sign in older patients

shortness of breath, ankle swelling, orthopnea, paroxysmal nocturnal dyspnea, history of cardiac risk factors, previous myocardial infarction, valvular heart disease

jugular venous distension, orthopnea, lower-extremity swelling, crackles in chest on auscultation, increased respiratory rate, third heart sound gallop rhythm on cardiac auscultation

recent myocardial infarction (MI); history of coronary artery disease, previous cardiac arrest, mitral or aortic valve stenosis, or structural heart disease; family history of sudden death; may occur in supine position or with exertion; absent or brief prodrome (<5 seconds) of palpitation and lightheadedness preceding syncope; valve replacement within the last 6 months

may be asymptomatic at presentation with no physical finding; or have hypoxemia, pulmonary rales, jugular venous distension, and hypotension

persistent low mood, anhedonia, fatigue, disturbed sleep, poor concentration, altered appetite, feelings of guilt, agitation, or slowing of movements, suicidal thoughts; older age, recent childbirth, stress or trauma, female sex

weight change, diminished libido, melancholy, sleep disturbance, poor concentration

polyuria, polydipsia, weakness, nausea, vomiting, drowsiness, and weight loss, developing rapidly over a day or less; may be precipitated by infection, myocardial infarction, stroke, or other endocrine disorders (e.g., history of diabetes mellitus)

signs of volume depletion, including tachycardia and hypotension, Kussmaul respiration, acetone breath, stupor, or coma

sweating, nausea, headache, drowsiness, seizures; usually history of taking medication for diabetes, or alcohol abuse

tremor, sweating, tachycardia, focal neurologic deficits, coma

history of extrarenal fluid loss (e.g., vomiting, diarrhea, burns); history of polyuria and polydipsia; diminished thirst response; inability to obtain fluid (e.g., bed-bound)

mental status changes, weakness, neuromuscular irritability, and/or coma/seizures[51]Rondon-Berrios H, Argyropoulos C, Ing TS, et al. Hypertonicity: clinical entities, manifestations and treatment. World J Nephrol. 2017 Jan 6;6(1):1-13. http://www.ncbi.nlm.nih.gov/pubmed/28101446?tool=bestpractice.com

anorexia, muscle cramps, headaches, altered mental status, including confusion, obtundation, coma, or status epilepticus; recent infection, recent medication change, and/or free water intoxication

confusion, seizures, coma[52]Hoorn EJ, Zietse R. Diagnosis and treatment of hyponatremia: compilation of the guidelines. J Am Soc Nephrol. 2017 May;28(5):1340-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5407738 http://www.ncbi.nlm.nih.gov/pubmed/28174217?tool=bestpractice.com

thirst; fatigue; muscle cramps; abdominal pain; chest pain; confusion

dry mucous membranes; orthostatic hypotension; postural tachycardia; shock

may be a history of being inappropriately dressed for a cold climate, or of being outside for a considerable amount of time; more common in older adults, children, and infants; may have increased urinary frequency

core body temperature lowered to <95°F (<35°C), measured using low-reading infrared tympanic membrane thermometer; early: increased respiratory rate, tachycardia, shivering, mood change, irritability, may show signs of frostbite; late: signs of pulmonary edema, coma, bradycardia, ventricular arrhythmias

usually secondary to underlying disease such as sepsis, pneumonia, pulmonary embolism, severe asthma attack, COPD, cardiac failure or arrhythmia, or carbon monoxide poisoning; symptoms include incoordination, poor judgment, seizures, myoclonic jerks, euphoria, nausea, visual impairment, coma

increased respiratory rate, tachycardia, cyanosis, poor coordination

dyspnea; disturbed sleep; chest pain; confused; somnolent; obtunded

diffuse wheezing, hyperinflation (i.e., barrel chest), decreased breath sounds, hyperresonance on percussion; prolonged expiration; rhonchi, respiratory distress

historic findings might include history of hepatitis infection, alcohol use, and/or drug use; can be precipitated by infection, gastrointestinal bleeding, constipation, diuretic overdose

asterixis; jaundice, hepatomegaly, ascites may be present

historic findings might include change in quantity or quality of urine output, anorexia, and/or nonsteroidal anti-inflammatory drug use

myoclonic jerks; pallor, edema, pleural effusion, pericarditis, neuropathy, and hypertension may be found

symptoms of localized infection, nonspecific symptoms include fever or shivering, dizziness, nausea and vomiting, muscle pain, feeling confused or disoriented; may be history of risk factors e.g., immunosuppression, pregnancy or postpartum period, frailty, recent surgery or invasive procedures, intravenous drug use or breach of skin integrity

tachycardia, tachypnea, hypotension, fever >100.4°F (>38°C) or hypothermia <96.8°F (<36°C), prolonged capillary refill, mottled or ashen skin, cyanosis, low oxygen saturation, newly altered mental state, reduced urine output

may have family history of psychiatric disorder; history of alternating episodes of mania, hypomania, and depression (although, despite being common, major depressive episode is not required for diagnosis of bipolar I disorder); requires fewer hours of sleep to feel rested, reports thoughts coming too fast to keep up with, distractible, increased goal-directed activities, excessive involvement in activities with high chance of painful consequences

speech may be pressured with racing thoughts and flight of ideas during manic episodes; flat affect during depressive episodes; no findings suggestive of secondary cause of psychosis

may have family history of psychiatric disorder; may be pregnant or have history of childbirth within last 4 weeks, or recent stress and trauma; history of ≥1 of delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior (at least one of these symptoms must be delusions, hallucinations, or disorganized speech), lasting at least 1 day but not >1 month, with eventual full return to premorbid level of functioning[14]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.

speech disorganized or pressurized, may jump from one subject to another with minimal connection, prolonged time elapsing between queries and answers (evidence of internal preoccupation), verbal responses to internal stimuli (evidence of hallucinations), delusions are generally very unstable and have rapidly changing topics, affect may be incongruent or flat, anxious, behavior may be grossly disorganized or catatonic, changing moods are more common than in schizophrenia, may be bizarre, repetitive movements that appear goal directed but are carried out in a stiff fashion; no findings suggestive of secondary cause of psychosis

anorexia, sweating, anxiety, auditory or visual hallucinations, agitation, nausea, vomiting, headache, disorientation hours to days after abruptly decreasing alcohol intake

underweight, jaundice, enlarged or diminished liver size, ascites; diaphoresis; tachycardia; hypertension; fever; altered sensation (particularly in lower extremities); muscle tenderness to palpation; tremors, broad-based gait

family history of alcoholism, antisocial behavior, economic or legal concerns; anxiety, low responsivity to effects of alcohol, nausea, vomiting

jaundice, enlarged or diminished liver size, ascites; diaphoresis, hematemesis, tachycardia, hypertension, altered sensation (particularly in lower extremities); muscle tenderness to palpation, cramps

overdoses with illicit or prescription drugs including anticholinergics, tricyclic antidepressants, stimulants, opiates, corticosteroids, analgesics, cardiac glycosides, and antiparkinsonian drugs can be associated with delirium; drug levels should be considered

anticholinergics: dry mouth, tachycardia, hypertension, absent bowel sounds; opiates: pinpoint pupils, decreased respirations

abrupt cessation of drug (e.g., selective serotonin-reuptake inhibitors, benzodiazepine or barbiturate); nausea, confusion, hallucinations, including tactile hallucinations and delusions

agitation; malnourishment, poor hygiene, smell of alcohol, tremulous, tachycardia, hypertension, low-grade fever

osteoporosis or osteopenia, age >65 years, female sex, low BMI and history of fall

pain in affected limb, groin, or proximal femur, with shortening and external rotation of the leg

prolonged bed rest or immobility, pregnancy/postpartum period, inherited thrombophilias, active malignancy, recent trauma/fracture, and history of previous thrombosis; chest pain, feeling of apprehension, cough, hemoptysis, syncope

tachypnea, dyspnea, syncope, hypotension (systolic BP <90 mmHg), tachycardia, fever, elevated jugular venous pressure, sternal heave, accentuated pulmonary component of second heart sound, unilateral swelling/tenderness of calf

traumatic event with loss of consciousness, although not always in older patients, who may present more insidiously with headache, lethargy, and/or personality changes

signs of head trauma; normal or focal neurologic signs; aphasia is rare

blunt trauma to temporoparietal aspect of skull, classic presentation of loss of consciousness followed by period of lucidity and subsequent neurologic deterioration; may have headache, vomiting, lethargy

physical exam may be normal, depending on location, size, and presence or absence of mass effect; ipsilateral pupillary dilation seen in 30% of cases

thunderclap or abrupt-onset headache, associated nausea, vomiting, and stiff neck, with or without focal neurologic deficits

nuchal rigidity or focal neurologic signs may be present

may present with unexplained weight loss, focal neurologic deficits, history of cancer; headache that awakens patient from sleep or is present on awakening, decreases after being awake for several hours, is aggravated by exertion or Valsalva

focal neurologic deficits

typically present with altered consciousness; may also exhibit altered or strange activity, such as facial or limb automatisms, dystonic posturing, and restlessness

neurologic exam can be nonfocal

may be past history of hypertension, use of sympathomimetic drugs or monoamine oxidase inhibitors; dizziness; headache; numbness; weakness; chest pain; shortness of breath

elevated BP, loss of sensation or motor strength, peripheral edema, new cardiac murmur, elevated jugular venous pressure, rales, oliguria or polyuria, fundoscopic changes associated with hypertensive retinopathy (arteriolar spasm, retinal edema, retinal hemorrhages, retinal exudates, papilledema, engorged retinal veins)

most common in people with nutritional deficiency (including alcoholics) or anorexia nervosa, or in professions where excess weight discouraged (e.g., jockeys, ballerinas, models); confusion, confabulation, impaired coordination, double vision

jargon speech, poor comprehension and attention, nystagmus, ophthalmoplegia, ataxia

history of hyperparathyroidism; malignancy, and/or thiazide diuretic use; nausea, vomiting, abdominal pain, constipation, anorexia, increased urination; altered mental status[53]Turner JJO. Hypercalcaemia - presentation and management. Clin Med (Lond). 2017 Jun;17(3):270-3. https://www.rcpjournals.org/content/clinmedicine/17/3/270 http://www.ncbi.nlm.nih.gov/pubmed/28572230?tool=bestpractice.com

signs of malignancy on examination; hypertension; hyperreflexia; tongue fasciculations; signs of dehydration (e.g., orthostasis, poor skin turgor)

history of neck surgery, muscle cramping; shortness of breath; numbness; abdominal pain

distal-extremity numbness; proximal muscle weakness; Chvostek sign (tetany); Trousseau sign (latent tetany); wheezing; bradycardia; stridor

nausea, headache, vomiting, blurred vision, dizziness

cutaneous blistering, tachycardia, hypotension, cardiac arrhythmias, pulmonary edema, confusion, coma

may be a history of exercising intensely under hot, humid conditions, or in older adults; central nervous system symptoms such as headache, anxiety, dizziness, irritability, ataxia; nausea/vomiting

generally associated with core temperatures >104°F (>40°C), although heat stroke can occur at lower core temperatures; increased respiratory rate, flushing, may be diffuse crackles on chest auscultation

weakness; skin pigmentation; weight loss; abdominal pain; diarrhea; salt craving; infection; history of corticosteroid use

signs of dehydration, tachycardia, increased respiratory rate, hypotension, rash or darkening of skin

change in appetite, weight loss, anxiety, palpitations, sweating and heat intolerance, oligomenorrhea, mood change, fatigue

goiter, lid lag, exophthalmos, tachycardia, proximal muscle weakness, tremor; thyroid storm also causes high fever and coma

reduced consciousness, usually in older patient with infection or oversedation; may also be weight gain, depression, lethargy, feeling cold, forgetfulness, constipation

coma, hypothermia, bradycardia, signs of cardiac and respiratory failure, dry skin, facial and eyelid edema, thick tongue

headache, diplopia, nausea, vomiting, altered mental status, 2:1 male predominance, most commonly seen in ages 37-57 years

visual deficits: ptosis, changes in visual field

fever, headache, stiff neck, rarely seizures; older patients present more atypically (afebrile, lethargic)

findings associated with meningeal inflammation: acute fulminant illness, and triad of fever, headaches, and nuchal rigidity; in meningococcemia, maculopapular rash and/or petechial rash; Brudzinski sign; Kernig sign; possible focal neurologic deficit[55]McGill F, Heyderman RS, Panagiotou S, et al. Acute bacterial meningitis in adults. Lancet. 2016 Dec 17;388(10063):3036-47. http://www.ncbi.nlm.nih.gov/pubmed/27265346?tool=bestpractice.com

initial fever plus malaise followed by speech difficulty, seizures, behavioral changes, impaired alertness; history of overseas travel; history of recent infection with infectious mononucleosis, measles, or rubella; may also experience convulsions

cognitive testing demonstrates language disturbance (aphasia, paraphasic errors in speech, anomia, apraxia) and evidence of temporal lobe seizures (staring, unresponsiveness, automatisms); West Nile encephalitis: may have bulbar paralysis and quadriplegia

personality change, gait impairment, incontinence, headache, lightning pains, blurred vision, photophobia, reduced color perception

hyporeflexia, ataxia, anisocoria, Argyll Robertson pupils, cranial neuropathy, dementia, paranoia

fever, headache, motor weakness, neck stiffness, vomiting, visual disturbance, seizures, impaired consciousness[57]Brouwer MC, Tunkel AR, McKhann GM 2nd, et al. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. http://www.ncbi.nlm.nih.gov/pubmed/25075836?tool=bestpractice.com

pyrexia, hemiparesis, focal neurologic abnormalities, septic shock, meningism, papilledema

chronic recurrent abdominal pain, usually worse after eating (referred to as abdominal angina); may lead to food phobia and weight loss; acute presentation with abdominal pain and bloody diarrhea may be secondary to acute ischemic colitis; presence of risk factors for vascular disease, including diabetes, hypertension, renal disease, cardiovascular disease, and/or tobacco abuse

subjective complaint of abdominal pain out of proportion to exam findings; signs of peripheral vascular disease may be present, such as diminished peripheral pulses or cool extremities; with severe atherosclerotic disease, an abdominal bruit may be heard

sudden-onset severe abdominal pain, pain commonly originates near the umbilicus or the epigastrium; often periumbilical with migration to right lower quadrant; nausea, vomiting, anorexia, fever, diarrhea, more common in children and young adults; pain may improve after rupture

fever, tachycardia, patient may be lying in right lateral decubitus position with hips flexed; no or decreased bowel sounds; right lower quadrant (McBurney point) tenderness with rigid abdomen; guarding and rebound tenderness; psoas sign (right lower quadrant pain with right thigh extension)

persistent left lower quadrant pain; fever, anorexia, nausea, vomiting, abdominal distension (with ileus), patient may have history of diverticulosis

fever, left lower quadrant tenderness, stool blood may be present, may have diffuse tenderness with peritoneal signs (guarding, rebound tenderness, rigid abdomen) with perforation or ruptured abscess

altered bowel habits; abdominal pain; pain on defecation

tender abdomen; mass on palpation