Formative Assessment for Simulation Training (FAST)—Altered Mental Status 2: Older, retired with metastatic dz to brain

Date: Examiner: Examinee(s):

Learning Objectives:

  1. Recognized acute mental status changes in a simulated patient
  2. Gathered from patient and family pertinent history
  3. Performed appropriate physical exam to include a quick MMSE and/or GCS if appropriate
  4. Listed a reasonable differential diagnosis (consider memory aid like MUDPIES)
  5. Ordered appropriate labs and rads to begin the emergent work up of a patient with acute MS changes
  6. Determined appropriate management and disposition for the patient based on the etiology of the MS change

CRITICAL ACTIONS / MS / ME / NI / SUSTAIN / IMPROVE
Place safety net—IV, O2, monitor & begin ABCs
ID altered mental status & assess patient as currently stable.
Take thorough history and ID time of onset
Evaluate MMSE and/or GCS as well as appropriate physical exam
Consider appropriate differential diagnosis using MUDPILES
Seek labs, rads to help with diagnosis
Choose appropriate acute management – intubation, surgery consultation
Admission to hospital
Demonstrate effective communication including closed loop feedback
TOTAL

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GCS: Glasgow Coma Scale (GCS) in adults:
  • best possible score 15 points, range 3-15 points
  • eye opening
  • spontaneously - 4 points
  • to verbal commands - 3 points
  • to pain - 2 points
  • none - 1 point
  • best motor response
  • follows verbal command - 6 points
  • localizes painful stimuli - 5 points
  • normal flexion withdrawal response to painful stimuli - 4 points
  • abnormal flexion (decorticate posturing) to painful stimuli - 3 points
  • decerebrate posturing to painful stimuli - 2 points
  • none - 1 point
  • best verbal response
  • oriented conversation - 5 points
  • disoriented conversation - 4 points
  • inappropriate words - 3 points
  • incomprehensible words - 3 points
  • incomprehensible sounds - 2 points
  • none - 1 point
Reporting GCS scores:
  • patient monitoring and information exchange should be based on 3 separate responses on eye-opening, verbal response and motor response (for example, communicate response as E4, V4, M5) (NICE Grade D)
  • if total score recorded or communicated, specify denominator (for example, 13/15) (NICE Grade D)
  • describe individual components of GCS in all communications and not just total score (NICE Grade D)

Mnemonic for differential diagnosis of delirium - AEIOU M&M TIPS

A - alcohol (including withdrawal)

E - epilepsy (especially post-ictal)

I - infection

O - oxygen (hypoxia)

U - uremia

M - myocardial infarction

& - anesthesia

M - metabolic

T - trauma/fracture

I - insulin

P - polypharmacy

S – stroke

Work up to consider:

vital signs

complete blood count with differential, erythrocyte sedimentation rate (ESR)

blood chemistries (electrolytes, blood urea nitrogen, creatinine, glucose, hepatic function, calcium)

thyroid studies (TSH, T4)

test for syphilis (for example, VDRL), HIV

B12, folate

urinalysis, urine drug screen

electrocardiogram (ECG)

chest x-ray

brain imaging (if focal neurologic deficits or suspicion for intracranial process - computed tomography, magnetic resonance imaging

lumbar puncture (if suspicion for meningitis)

electroencephalogram (EEG)

often shows diffuse slowing of background activity

may show seizure activity

fast if drug withdrawal

References:
  • National Institute of Clinical Excellence (NICE) guideline on head injury (triage, assessment, investigation and early management of head injury in infants, children and adults) (NICE 2007 Sep:CG56 or at National Guideline Clearinghouse 2010 Jun 21:11468), summary can be found in BMJ 2007 Oct 6;335(7622):719
  • Lancet 1974 Jul 13;2(7872):81
  • Am Fam Physician 1998 Mar 15;57(6):1358
  • J Am Geriatr Soc 2008 May;56(5):823
  • DynaMed search database
  • UptoDate search database