Friday, October 31, 2008

Altered Mental Status (Scary Halloween Post!)

"Altered Mental Status" is a challenging workup in the ER. These patients come in by ambulance or are hauled in by family because they are "not their normal selves".

As a physician one must act quickly as some causes of altered mental status are life threatening. A CT scan of the brain is almost always ordered, and sometimes it provides an answer.

The scan above shows a meningioma and, similar to the XRays from a few days ago, is an 'incidentaloma' in this case. The patient above was near death when he arrived, was severely dehydrated, but should do well nonetheless. Unfortunately, as can be seen from his scan, he is very old, has severe cortical atrophy and, at baseline, is quite demented.

Without writing an exhaustive post about altered mental status it is amazing what slight alterations either in brain chemistry or brain structure can do. For instance, while the patient in question was comatose upon arrival other people with "altered mental status" are combative and require restraints.

If this meningioma was more toward the front of the brain and a bit higher one might see all manner of bizarre behavior as the frontal lobes act as the seat of personality and judgement. Occasionally, patients with frontal lobe tumors (or injury) exhibit frontal release signs, and I'm sure right now there is a medical student or neurology resident busily memorizing these.

Many times the cause of altered mental status is immediately obvious on history and physical exam ("two beers"), but occasionally patients manage to speak quite coherently for a bit before you realize that they are way, way off. In fact, it is a curiosity that many people are able to "cover" a bit as, theory has it, on some level they realize that they are confused but do not want you to realize it. This curiosity is called "confabulation".

The real question is whether the patient will recover, and this leads to a long and complicated differentiation between "dementia" and "delirium" which is quite beyond the scope of this post.

Finally, "delusions" are fixed, strongly-held beliefs that are demonstrably false, and when these are combined with "psychosis" the results can be devastating. Witness the following...

Other forms of altered mental status are more subtle, perhaps the most difficult to diagnose is transient global amnesia... a temporary and quite complete loss of memory. This is a diagnosis of exclusion in the ER, and is related to the rarely seen fugue state, which is demonstrated in the following...


  1. Disgruntled Internist6:55 AM, October 31, 2008

    Two diagnoses drove me out of geriatrics: "syncope," for which one finds a cause about 1% of the time, and "altered mental status," which is really "code language" for 1) drunken old man 2) chronically demented old person who is just noticed to be demented by a relative who hasn't visited in 7 years or 3) lethargic demented old person who becomes an alert demented old person with IV fluids and antibiotics.

    Speaking of old demented people with a different mental status each day, what do you plan to write about on November 5, when McCain loses the election in an electoral college landslide?

  2. My aunt had a meningioma and lost her vision. When I talked to her in the hospital after the surgery, she was seeing little green men and I made sure to write down exactly what she said because I knew as soon as the swelling went down and she was back to her normal self she would laugh like crazy about the things she had said and done.

    She and I both found all our medical stuff being in a room with "caution, do not enter: radioactive material inside" taped across the door and her with her little green men. For some reason, no one else seems to find any of this funny at all. Which makes me happy to have her, someone I can laugh with over these things who totally gets it. It isn't funny in reality, but you can only laugh at the absudity of it all.

  3. Radgirl: Actually, being hearing impaired is comedy itself: The stuff I think I hear is always funnier than anything I could invent.

  4. I can't stand to look at his face and listen to Obama stretch out his S's like a pseudo-southern preacher. I could go on about his Marxist leanings, but he really isn't a friend to the black man. He might as well be a rich elite white liberal pandering to the poor, keeping the $5 handouts for votes coming, and solidifying power. That is all they want, power. MLK would take one look at this man and his "plan" for the poor and inner city blacks and vomit.

    In the elections of 72,76, and 80 the Dems and Reps were interchanged as Red and Blue states (look it up). Some networks had the Reps as the Blue states. But starting with the further left leaning Carter a decision by the liberal media not to have the Dems as Red states as it has conotations of Communism/Marxism, and since 80 the made the Reps red. Funny, huh.

  5. just fyi, i'm not reading this blog anymore. i come here to read about medicine, not politics, but lately all i've been reading are a bunch of lame ad hominem/below the belt attacks at barack obama and liberalism in general. it doesn't bother me that you guys are all super conservative... what bothers me is that your area of expertise is EMERGENCY MEDICINE, not politics. in the realm of politics, none of you are any more qualified to speak from a soap box than your precious "joe the plumber". anyways, thanks for all of the interesting/entertaining medical anecdotes over the years, and i'm sorry it had to end this way. heh.

  6. speak

    Most of us are more qualified than your elbow-patch, smoky, plaid jacket wearing 60's reject that is indoctrinating our kids at "college". I have a medical degree and a degree in chemistry, but over the past few years I have read over 100 history/political science books ranging from our founding fathers to current events, so, yes, I believe I am qualified.
    The ones who aren't qualified and the 20 somethings eating cheetos blogging on the daily kompost living in their mom's basement, bumbed out that Blockbuster fired them for being late for the 20th time.

  7. So Ahhhnold was wrong after all, it really is a "tumah." This explains much. Bless you, 911.

  8. Yeah, Cat, regular Americans like you guys don't have the ability to comprehend politics. Certainly you are not equipped to discuss as you don't worship at the altar of the social progerssive. You need people like the NY times and Bill Mahr to break it down for you. That way you will believe anything as long as Jesus, oops, I mean Obama says it.

    Have a nice long drink of the koolaid, it's for your own good you know.

  9. These types of posts crack me up."I am not going to read your blog any more." Well then dont and fuck off! Dont come here whining about it like the bleeding heart pussy you are, just go on with your miserable self.

  10. My husband has had 9, yes 9, very well documented attacks of transient global amnesia in the last 11 years. We need a new neurologist...someone who has an expertise with this phenomena. I am at my wits end!

  11. I know that you don't like to suggest treatments in the comment section but I just don't who else to turn to.

    I have cronic health flex spending hate coupled with severe cobra irratation. If I don't get some relief soon I'm afraid it will turn into full blown postal rage.

    Any suggestions? Oh and please keep in mind that since I am paying for cobra and can't get my $ out of the flex spending account that I can't afford any therapies that cost over $10 otherwise I would have ran away to Hawaii a long time ago.


  12. AC, Barak Obama has a salve he would like to apply to your rash. It won't help, but it will restore negative pressure to your bank account and realign the planets. Be careful though, too liberal an application can cause anal drippage, anal seepage, and genital warts.

  13. dear speakeredtext,

    so sorry to see you go... will not read your blog anymore either, so there.

  14. I'd be one of those bitter clingers bo so lovengly spoke of.


  15. Dear Speaker.....

    Ahhh...another liberal who when not attempting to "save and deliver" the middle class, can hardly contain their disgust and contempt for the same such members of the middle class.

    So tell me....what did these people know about politics?

    *Silversmith aka Paul Revere

    *Printer aka Benjamin Franklin

    *Personal Assistant and a bastard to boot aka Alexander Hamilton

    *MD (imagine that!) aka John Locke

    *Excise officer and teacher aka Thomas Paine

    *Failed businessman, planter aka Patrick Henry

    *Shipping merchant aka John Hancock

    *Surveyor, planter, General aka George Washington

    Our Founding Fathers based many of their ideals on the classical tradition of "civic virtue" Politics was NEVER intended to be a full time occupation, but instead a moral and intellectual pursuit aimed at improving one's character. George Washington was almost obsessed with this.

    I think I have provided enough evidence to expose what a fool you are.

    Don't ever fuck with a nurse that holds a history degree from an Ivy League University.

  16. What do you recommend for nausea?

  17. Barak is going to burn the village in order to save it.

    I'm starting to be really frightened of this man.

  18. This is the kind of shit that would be on the major networks every single night except for two things: 1) Fear of ridiculous protests of racism. 2) Media bias. Remove these two factors, and BO doesn't even come close to a win on Tuesday. With them, he's virtually guaranteed one.

    HA HA HA HA "...the best of what the black church has to offer." HA HA HA FUCKING HA. Which is exactly why he had to distance himself. Right. BO's lies and attempts to hide his true self are just absolutely fucking hilarious.

  19. In college I worked delivering Pianos, occasionally taking one to a Black Church. Without fail, they'd try and rip the store off, substituting a delapidated Upright for the brand new Kwai Baby Grand, then they'd cry "Discrimination" when we'd call the Cops. Thank God it was Alabama or we'd never have made any money.

  20. Fun with CT scans!

    Man, you docs really know how to party, Halloween-style!

  21. Jennifer - Again, I say YOU ROCK! I loved your history lesson - I didn't know some of that information about our founding fathers (I am ashamed to admit). I'll bet many Americans don't either. Thanks for the refresher -feel free to teach anytime as far as I'm concerned. Loved this post, 911.

  22. Is it just me or does it seem like every liberal thinks you guys actually give a flying crap whether they read your blog or not. Is this mandated reading by the Federal Blog Police? Do you have to conform to some liberal governmental touchy-feely, let's all sing while holding hands together approach? Not everyone in this world believes that "if it feels good do it" approach is something that we should all follow. I'm sure after Tuesday's election, and come January, it will be BO's and Ms Pelosi's personal stance that all blogs must speak so as to never offend another person. God help us all.

  23. very nice blog site some how i found you looking for things on our sons birth defect esophageal atresia, i wish you all the best.

  24. I like the "CURSOR" written in crappy Paint-scrawl pointing to a cursor. Very informative.

  25. I have a medical degree and a degree in chemistry, but over the past few years I have read over 100 history/political science books ranging from our founding fathers to current events, so, yes, I believe I am qualified.

    The daughter and I had a talk about this when she was disgusted by one of her US history classes in college - an undergraduate requirement she had to fulfill. The class cost around $600 (that's our out-of-pocket, not counting the part that was subsidized by the state). If it weren't for needing to jump through this hoop to get that sheepskin, just think how much better your history education would be if you spent that money on books instead. Rather than getting just one book and one professor's opinion, you could buy several books written by experts on the subject, possibly expressing different perspectives and thus contributing to a more rounded understanding. Too bad you can't simply pass a knowledge test instead to obtain credit. The efficiency, cost effectiveness, and outcome would be superior if this were an option.