Patients with altered mental status can challenge medics. Managing such patients is fraught with pitfalls that can be medically and legally significant.
You are called to a residence in an upscale neighborhood to assist police where a teenage party has been going on. No adults are present. Called by neighbors because of excessive noise, police found a young female, minimally responsive and possibly overdosed on ETOH/drugs, lying on a sofa and responding only to loud verbal and painful stimuli. Her responses to your questions consist mainly of curses, "Leave me alone," and pushing you away. Her appearance and vital signs are as follows:
- Hot, dry, pink skin;
- Pulse: 126 bpm;
- Respirations: 24/min.;
- BP: 160/120;
- Tympanic temperature: 100.5°F;
A patient with an altered level of consciousness should be approached carefully and in a nonconfrontational manner. Patient rapport is essential to obtaining a thorough assessment.
Observation of the patient's surroundings may yield valuable clues. Is there evidence of ETOH or other drug ingestion, such as drug paraphernalia, empty bottles or telltale smells?
Assessment of the patient with altered mental status must include the following key elements:
1. Level of consciousness. Is the patient aware of his surroundings?
2. Attention. Is the patient able to focus or concentrate on one task at a time, or is he easily distracted?
3. Memory. Can the patient record data in the brain and repeat it at will? Thorough assessment of memory includes short-term memory, such as the ability to repeat a sequence of objects several minutes after they are first introduced, and long-term memory, such as the names and birth dates of family members or being able to repeat the alphabet.
4. Cognitive ability. Can the patient process abstract thoughts coherently, such as explaining, "Why can't pigs fly?" Can he perform simple math or word problems, such as "Subtract 7 from 100 as many times as you can," or "Spell the word world backward?"
5. Affect and mood. Affect is an objective assessment of the patient's demeanor and reaction to stimuli, while mood is a more subjective assessment of the patient's emotional state. Are both of them appropriate for the patient's current situation?
6. Probable cause of the present condition. What is the underlying pathophysiology causing the patient's altered mental state? One commonly used mnemonic is AEIOUTIPS:
- Alcohol, ingested toxins;
- Epilepsy, endocrine, exocrine or electrolytes;
- Overdose, opioids or oxygen deprivation;
- Infection, inherited defects;
- Psychosis, porphyria;
- Stroke, shock, space-occupying lesions.1,2
1. What's your name?
2. Do you have any medical problems? Are you seeing a doctor? What medications do you take? Can you show them to me? Have you had any alcohol or recreational drugs today?
3. Will you play a game with me? Will you try to remember three things I'm going to tell you? Book, candle, scissors. Repeat these to me. [Continue until the patient can repeat the three objects. If he cannot, the test is failed.]
4. Where are you right now?
5. What day is it?
6. What's your Social Security number?
7. What's your birthday?
8. Where were you born?
9. Say your ABCs, starting with G and ending with S.
10. Count backward starting with 13 and ending with 4.
11. Spell world backward.
12. What were the three objects I asked you to remember? [book, candle, scissors]
13. Take this sheet of paper in your right hand and read and do what it says. [It says "Close your eyes."]
14. Take the piece of paper I handed you and fold it in half and then in half again, and then place it on the floor (table, etc.).3 What constitutes failure? Failure of one or more of the tests indicates lack of present mental capacity to make an informed decision about treatment.