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Altered Mental State-mdm

Chapter Seven

Altered Mental Status 1- A newborn with a two day history of diarrhea is in coma. In Physical Examination he has pin point pupils. He suffers bradycardia and bradypnea as well. What drug is the most likely reason for his condition? A- Atropin B-Methoclopramide C-Barbiturates D-Opioids 2-A three year old child becomes comatose and convulsive within hours. He has mydriasis and hyper reflexia. What drug overdose is the most likely reason for his condition? A- Opioids B- phenothiasines C- Organophosphates D- TCAs 3- A child has a history of drug intoxications. His abdominal x ray shows a radio-opaque material in his abdomen. Some weeks later, he shows signs of bowel obstruction. What is the most likely reason? A- Iron B- Lead C- Arsenic D- NAOH 4-A child is brought to ED with fever, and vomiting started 3 hours ago. In physical examination he is lethargic, and tachypneic. ABG reading is: PH=7.55 /HCO3=16mmol/l /PaCO2=18mmHg /PaO2=90mmHg / SaO2=95.5%. What drug is the most likely reason for his condition? A- Acetaminophen B-Aspirin C-TCA D-Iron 5-A 2 year old comatose child is brought to ED. He is hospitalized in ICU. His GCS is 10 (E2V3M5). Respiration is normal. Pupils are mydriatic but responsive to light. Doll’s eye maneuver is positive. He is told to have taken a drug. What drug can not be suspected? A- Phenobarbital B- Dyphenhydramine C- Amitriptylene D- Imipramine


6-A three year old child is brought to ED in coma. Before he became comatose, he had head ache and dizziness. RR=60/min, PR=100bpm, T=37 C. Pupils are mydriatic. There are some blisters on the skin. What is the most probable cause of his toxicity? A- CO B- Ethylene glycol C- Organophosphate D- TCAs 7-A 30 year old man is in coma. His pupils are pin-point bilaterally,but responsive to light. What is the most likely cause? A- Acute hydrocephaly B- Pons hemorrhage C- Metabolic encephalopathy D- Putamen Hemorrhage 8-A 70 year old man has developed right hemiplegia. His head CT scan shows left brain hemisphere infarct. His BP is 170/100.There’s no papilledema. What is the best management? A- SL Adalat B- Adrenaline to raise BP C- SNP D- No need to treat hypertension for the time being 9-A 65 year old man comes with left hemiplasia. His BP is 180/105mmHg. His head CT scan shows no sign of hemorrhage. What is the best drug? A- SL Adalat B-Aspirin C- Dexamethasone IV D- Heparin 10-Which dosage is wrong? A- Sodium Valproate: 750-2000 mg B- Carbamazepin: 600-1200 mg C- Phenobarbital: 90-180 mg D- Phenytoin: 500-1000 mg 11-What anticonvulsant drug is appropriate for a 12 year old girl with 3 episodes of convulsions. The convulsions are in sleep and start from one side of the body? A- Clonazepam B- Ethosoximide C- Pirasetam D- Carbamazepin 12- A 15 year old boy had tonic-clonic seizures 15 minutes ago for the first time. He is not in coma. What is the best thing to do now? A- Glucose check B- Diazepam 10 mg IV C- Phenytoin IV 500 mg D-Head CT


13- In an acute ischemic CVA patient, which drug is better? A- Corticosteroids B-Antihypertensive C- Heparin D-Manitol 14- A 30 year old man experiences episodes of epigastric discomfort, staring, and bruxism which last for some minutes. EEG is non specific. He doesn’t respond to 150 mg phenobarbital. What should be done? A- Increasing the dose of Phenobarbital B- Starting Carbamazepin C- Adding Sodium Valproate D- Psychiatric consultation 15-For a case of status epilepticus 20 mg Diazepam IV followed by Phenytoin IV 30 mg/kg is started. This doesn’t stop the convulsions. What should be done? A- Repeating phenytoin B- Dexamethasone IV C- Halothane D- Phenobarbital IV 20mg/kg 16- A patient in coma is hypothermic. Which is the least possible cause? A- Sedatives B- Hypoglycemia C- Anticholinergics D- Wernike encephalopathy 17- A 75 year old man notices right hemiparesia and speech disturbance. He had experienced the same signs one month ago which lasted for 10 minutes. Which type of stroke has happened? A- Embolic B- Hemorrhagic C- Thrombotic 18- Which is the correct dosage? A- Phenobarbital: 180-300 mg/day B- Sodium Valproate: 200-400 mg/day C- Carbamazepin: 600-1600 mg/day D-Phenytoin: 400-600 mg/day 19-How should phenytoin be administered in cases of status epilepticus? A- The infusion rate should not exceed 50 mg/min B- The dosage should not exceed 10 mg/kg C- The drug should be diluted in DW5% D- Glucose, Thiamine and phenytoin are the first drugs in convulsions


Figure 7-1: Diagnosis the etiology of coma

Coma

Doll’s eye maneuver to R/O hysteria

Pupils Reflexes

Responsive to light but

small

Pin point pupil

Normal Not responsive to

light

Unilateral

Thalamus hemorrhage

Opioids Pons hemorrhage Organophosphate

Barbiturate phenothiazine

Liver etiologiesMyxedema

Wernike encephalopathy

Brain stem

problemhypoglyce

mia

Miosis in darkness

Mydriasis in light

Horner CVA

Tumor Trauma

Migraine Carotid tumor

Aneurism Caverno sinus

EDH Adie

Gluthetamide Barbiturates

Anoxia Anticholinergic

Opioid Hypothermia

Brainstem problems SAH

TB meningitis Orbit problem

Hyper reflexia= hypoglycemia

Hyporeflexia=myxedema

No reflex=Wernike encephalopathy


Figure7-2: algorithm for the treatment of cerebrovascular accident (stroke) or suspected stroke


Figure7-3:Algorithm for the management of acute poisoning. AC = activated charcoal; BARAs = beta-adrenergic receptor antagonists; CCAs = L-type calcum channel antagonists; HF = hydrofluoric acid; MDAC = multidose activated charcoal; NS = 0.9% saline solution; PEG = nonabsorbable polyethylene glycol solution.


Table7-1: Specific therapy Acetaminophen-----------

Amphetamines------------

Beta-adrenergic receptor antagonist-


L-type CCB----------------

Cardiac glycosides-------

Cyclic anti depressants------------


Ethylene Glycol----------

Gama hydroxy-butyrate--

Lithium--------------------


Opioids---------------------

Organophosphates-------

Salicylates----------------


Figure 7-4: Algorithm for the early management of meningococcal infection.


-Was this a seizure?

-Is this the first adult generalized seizure?

-Has hypoglycemia been excluded?

-Does this patient require an urgent CT?

New focal neurological deficit.

Persistent altered mental status.

Fever or persistent headache.

Recent head trauma.

History of cancer or HIV infection.

History of anticoagulation or bleeding diasthesis

History of stroke or TIA

Is the patient’s follow- up ensured?

Are the ECG and blood results ( prolonged QT-uremia- Na –Ca- Glu-...)normal?

If the patient meets discharge criteria:

Give written advice about driving and lifestyle changes. Discharge and arrange

follow-up at first seizure clinic. Attach patient ‘s notes, investigations and

assessment page to the referral.

Figure7-5: Questions to be answered for adults with an uncomplicated first generalized seizure

Answers: 1- D 2-D 3- A 4-B 5-A 6-A 7-B

8-D 9-D 10-D 11-D 12- A 13- C 14-B

15-D 16- C 17- C 18- C 19-A


References: 1- Aminoff Michael J, et al. Clinical Neurology. 5 th edition. McgrawHill; 2002 2-Anderoli Thomas E, et al. Cecil Essentials of Medicine. 5th edition. W.B.Saunders; 2001 3-Behrman Richard E, et al. Nelson Essential of Pediatrics. 4 th edition. W.B.Saunders; 2002 4-Braunwald Eugene, et al. Harrison's Principles of Internal Medicine. 15th edition. McGrawHill; 2001 5- Dunn,M J. Breen ,G D. Davenport ,P. and Gray ,A J. Early management of adults with an uncomplicated first generalised seizure . Emergency Medicine Journal 2005;22:237-242. emj.bmjjournals.com/cgi/content/full/22/4/237 6- Ford, Marsha D.. Cecil text book of medicine. Acute poisoning.Saunders company.2004. www.merckmedicus.com/ppdocs /us/common/cecils/ chapters/ 106_006.htm 7-Iranian Council for Graduate Medical Education. Exam questions. 8- Pollard AJ, Nadel S, Habibi P, Faust I, Maconochie I, Britto J, Levin M Meningococcal Infection. Department of paediatrics, Imperial College School of Medicine, St Mary's Hospital, London. 1998. adc.bmjjournals.com/cgi/content/full/80/3/290 9-Regional ALS Treatment Protocols and Procedures.EMT-Paramedics,1998 10- www.Nurses Drug handbook.com.Nursing Spectrum.Emergency Medicine Guidekine.stroke treatment guidelines.2006

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