Altered Mental Status



  • Acute state of confusion w\ an organic cause, alteration of consc., If unrecognized has high mortality, if treated promptly can be reversible


  • Gradual deterioration of higher cortical function w\ an organic cause, preserved consc., rarely completely reversed

Acute psychosis:

  • Inability to differentiate between reality and fantasy

Altered mental status 1



  • MCC in elderly is multifactorial, medications, infection, metabolic disturbances, trauma, neoplasm, CVD, dehydrations
  • Infections in elderly present usually as acute confusional states rather than classical sx seen in young pt (fever, tachycardia, pain)


Physical Exam:

  • Vital signs
    • ↑ temperature: infection, heat stroke
    • Resp rate and pattern: clue about intracranial pathology or acid-base disorders
    • ↑ICP: ↑BP, widened pulse pressure, ↓HR (cushing reflex)
  • Head:
    • Breath odor:
      • DKA: fruity, ketones
      • Liver failure: fetor hepaticus
      • Cyanide: almonds
      • Arsenic: garlic
    • Signs of trauma: hemotympanum, cephalohematoma, CSF leak (halo sign), battle sign, raccoon eyes
  • Eyes:
    • Unilateral dilated pupil in an alerted pt -> herniation until proven otherwise (pathology is usually on the same side as the dilated pupil)
    • Bilateral pupillary constriction (pinpoint pupils) -> opiate overdose
    • Funduscopic exam: Flame hemorrhage in hypertensive bleeds, papilledema in high ICP
    • Eye movements: if eyes are fixed in one direction: they “look” toward the side of hemorrhage OR away from a destructive lesion
    • Oculocephalic reflex (doll’s eyes) -> MLF
    • Oculovestibular testing (cold calorics)
  • Neck:
    • Nuchal rigidity: meningismus
    • Examine thyroid\parathyroid
    • Pulmonary:
    • Signs of hypoxemia\hypercarbia -> signs of COPD
    • Signs of consolidation -> pneumonia
  • Cardiac:
    • Signs of dysarrhythmias or valvular heart disease: heart sounds (irregular rhythm, extra HS S3), murmurs, rubs
  • Abdomen:
    • Signs of infection: localized tenderness, rebound tenderness, rigidity
    • Signs of liver failure: enlarged\small, nodular, stigmata of chronic liver disease
    • Pancreatitis and ruptured AAA signs: Cullen’s and Grey Turner’s sign
  • Neurologic:
    • Automatisms -> brainstem or frontal lobe pathology
    • CN
    • Motor + sensory testing
    • Deep tendon reflexes


Mental Status Assessment:

  • GCS
  • AVPU
  • Orientations assessment: person, place and time
  • Memory (short-term): ask pt to remember 3 common objects, recall them 3 mins later
  • Mini-mental status exam (MMSE): geared more towards dementia and content of thinking
  • Confusion assessment method (CAM): best for delirium, done while observing pt responses during Hx\PE


  • “DONT”
  • Volume replacement
  • Temperature control



Download the PDF version: here


  • An introduction to clinical emergency medicine
  • Clinical emergency medicine

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