altered mental status 11.30.2011

8/3/2019 Altered Mental Status 11.30.2011

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Case ofAltered

Mental StatusMorning Report

11/30/11



History

• CC: right leg weakness

• HPI: 17 yo male w/ hx of depression who presentswith slurred speech and with acute onset of right leg

weakness and numbness that progressedsuperiorly to include arms and face. He was walkingdown the steps at his friend’s house when the RLweakness was noted. Later in the afternoon, he wasnoted to have drooping of the right side of the face,slurred speech, inability to walk, and altered mentalstatus. Patient was staying at a friend's houseduring this time, so the parents are unaware of all ofthe details. No history of recent head trauma.



History

• The patient’s brother takes Abilify and thepatient takes Celexa for management ofdepression. Work-up done at another

Hospital and transferred to PrimaryChildren’s for further management.

• PMH: History of depression. Remote history

of childhood asthma, now resolved.

• PSH: No surgeries



History

• Imms: Up to date

• Medications: Celexa 40mg po daily

• Allergies: NKDA

• FH: Brother with history of Bipolar Disorder. No other chronicconditions.

• SH: Lives with mother and brothers. Parents are divorced. Heis a senior in high school and is very involved in soccer.

• ROS: no SI/HI, no recent cough, rhinorrhea, congestion, sorethroat, fever upon arrival to the floor



Physical Exam

• T 38.4. HR 90. RR 28. BP 97/53. SaO2 95% onRoom Air.WEIGHT - 58 Kg

• GENERAL: Resting in bed but arousable,sleepy when answering questions

• HEAD: normocephalic, atraumatic.•

EYES: normal red reflex and pupillary reflexesbilaterally, extraocular movements intact,conjugate gaze, no conjunctival injection.fundoscopic exam with sharp optic disks.

• EARS: tympanic membranes gray bilaterally,



• NOSE: no discharge or obstruction.• OROPHARYNX: moist mucus membranes.• NECK: supple without lymphadenopathy ortenderness to palpation.

• CARDIOVASCULAR: normal rate, rhythm, andS1/S2, without murmur or gallop. Pulses

appropriate. Capillary refill time 3 seconds.

• LUNGS: clear to auscultation bilaterally, goodair flow, no retractions.



Physical Exam

• ABDOMEN: soft, non-tender, non-distended with activebowel sounds and no masses or hepatosplenomegaly.

• EXTREMITIES: all extremities warm and well perfused. Nocyanosis, clubbing, or edema.

• BACK: no abnormalities noted• NEUROLOGIC: MS exam notable for decreased attention.

Answers questions appropriately but is sleepy ( slurringspeech with answers in ED), normal strength and bulk in UE

and LE BL and able to follow commands, CNs II-XII intact(reported facial asymmetry in ED), no sensory deficits, DTRs2+ in all extremities.

• SKIN: no rashes, purpura, or petechiae



Altered Mental StatusDdx

• M: Metabolic

• O: Hypoxemia (pulmonary, cardiac, anemia)

• V: Vascular causes—hypertensive emergency,ischemic/hemorrhagic CVA, vasculitis, TTP, DIC

• E: Electrolytes and endocrine

• S: Seizures / status epilepticus, post-ictal andnon-convulsive status epilepticus



AMS Ddx

• T: Tumor, trauma, temperature, toxins—mass effect,bleed, hyper/hypo-thermia, lead, mercury, CO

• U: Uremia. Renal or hepatic dysfunction withencephalopathy

• P: Psychiatric, porphyria

• I: Infection (inflammatory-see vasculitis above), Insulin

•

D: Drugs, including withdrawal (anticholinergics, TCA;s,SSRI’s, BZD’s, barbiturates, alcohol)

•



Labs

• Negative Toxicology screen

• CBC w/diff: WBC: 8.1 (44N, 44L, 9M), Hct: 46.8, Platelets: 180

• CMP: Na: 140, K: 3.9, Cl: 106, Bicarb: 26, BUN: 13, Cr: 0.8, Glucose:

83, Ca: 10.5, AKP: 238, ALT: 21, AST: 31, Bilirubin: 1.2, Protein: 7.8,Albumin: 5.0

• UA: 2+blood, 0WBC, negative ketones/bilirubin/nitrite

• CBG: 7.41/37/39/23/1

• TSH: 0.62, Mg: 2.0, Phos: 4.1

• CSF: WBC 228, RBC <1, 96%L, 4%M, protein: 90, glucose: 51, negEnterovirus, neg HSV, neg gram stain



Imaging

• Normal EKG

• Head CT: normal

• MRI: normal



Viral Meningitis

• Inflammation of the meninges, manifest by cerebrospinal fluid(CSF) pleocytosis

• Aseptic meningitis is the clinical syndrome of meningealinflammation with negative cultures

• 26,000 to 42,000 hospitalizations annually

• Infants less than 1 and children 5 to 10 years of age

• Late spring to autumn months

• Infect mucosal surfaces of the respiratory/GI tract, followed byviral replication in regional lymph nodes.

• Viremia seeds other organs and reaches CNS



Etiology

• Etiology:

• - Enterovirus (85-95 percent of cases)

• - Paraechovirus

• - Herpesviruses

• - Varicella zoster

• - CMV, EBV, HHV-6/7

• - Arbovirus : West Nile Virus, Eastern/Western equine encephalitisviruses)

• - Influenza, rabies, human metapneumovirus (less common)



Symptoms/History

• Fever, stiff neck, headache, photophobia

• Altered mental status, paresthesias

• Rash, sore throat, vomiting, diarrhea

• Preceding illness

• Exposure to ticks, mosquitoes, contact withrodents, swimming in hot springs



Physical Exam Findings

• Signs of meningeal inflammation (nuchalrigidity)

• Assessment of mental status/presence of focalneurologic signs

• Conjunctivitis, pharyngitis

•

Generalized lymphadenopathy, oral or genitalulcers, rash

• Weakness or paralysis

https://legacy.umail.utah.edu/owa/redir.aspx?C=0b84d35d5c964488a77d33b462054b0c&URL=http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-enterovirus-and-parechovirus-infections?source=see_link

https://legacy.umail.utah.edu/owa/redir.aspx?C=0b84d35d5c964488a77d33b462054b0c&URL=http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-enterovirus-and-parechovirus-infections?source=see_link



Imaging

• CT of the brain is indicated if there is historyof altered mental status, papilledema, focalneurologic deficit

• Should be done prior to LP if there isevidence of increased ICP

•

MRI may be helpful in assessing braininflammation and making the distinctionbetween meningitis and encephalitis.



Treatment

• HSV- Acyclovir

• Concern for bacterial meningitis- provide

broad spectrum coverage withCeftriaxone/Vancomycin

• Supportive care (fluids, pain medication)

• Improvement of symptoms after LP



Prognosis

• Complete recovery

• Fatigue, irritability, decreased concentration, muscle weaknessand incoordination for several weeks after the acute illness

• Other complications: hearing loss, paralysis, learningdisabilities, blindness, behavior disorders, seizure disorders

• Depends upon the age of the child and the etiologic agent.

• Neonatal or immune-compromised hosts, the rates of

sequelae and mortality are higher (mortality < 1% in otherpopulations)

altered mental status 11.30.2011

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