What Are You Specifically Looking for During a Focused Physical of a Patient with Altered

2005 EMT-Intermediate Curriculum Rollout

Altered Mentation Study Guide

Terms and Key Points

Define and give an example of

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Altered mental status

Consciousness

Cerebrum

Cerebral cortex

Reticular activating system (RAS)

Level of consciousness

Herniation

Glasgow coma scale

Cincinnati stoke scale

Cerebral concussion

Cerebral contusion

Epidural hematoma

Subdural hematoma

Intracerebral hemorrhage

Ischemia

Infarction

Thrombus

Embolus

Cheyne-stokes respirations

Central neurologic respirations

Biot’s (ataxic) respirations

Apneustic respirations

Hemiplegia

Hemiparesis

Hypermetabolic state

Dysphasia

Aphasia

Syncopal episode

Brudzinski’s sign

Kernig’s sign

Ataxia

Hypercapnia

Polyuria

Polyphagia

Polydipsia

Encephalopathy

Jaundice

Ocular icterus

Spider angiomas

Edema

Ascites

Fector hepaticus

Oliguria

Tetany

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List at least two causes of AMS for each of the following six general classifications:

Structural:______

Metabolic ______

Drug Induced______

Cardiovascular______

Respiratory______

Infection______

You are called to care for a patient who is suspected of suffering from a neurological disorder. He opens his eyes when you call his name but does not know what day it is. He is moving all extremities normally.

List six specific questions you should ask to elicit the nature of the neurologic problem.

What vital sign findings would suggest increased ICP?

Using GCS assessment, describe his level of consciousness.

What are your treatment options? Defend your answers.

You arrive on scene of a suspected diabetic emergency. You find a 35-year-old male whose wife says he took his insulin 2 hours ago and has not eaten. He arouses only to pain and has noisy, snoring respirations. He has no other medical history. Outline the steps in your patient management. Defend your responses.

List six factors that predispose a patient to the development of hyperosmolar hyperglycemic nonketotic coma.

A 20-year-old diabetic patient calls you complaining of difficulty breathing. On arrival, the patient states he has had the flu for 2 days. You note that his respiratory rate is 40/bpm and his breath has a very sweet odor. You auscultate his lungs, his breath sounds are clear.

What do you suspect?

What specific questions will you ask?

What specific findings are you looking for?

You preform a blood glucose analysis and your machine reads “high”. He also appears dehydrated.

What interventions should you perform for this patient? Why?

You are called to care for an 20-year-old female suffering from an unknown medical problem. You find an unresponsive patient supine in bed. Her roommate tells you that she has had the “flu” for two weeks now and has not been out of bed. She is pale, BP 98/60, HR 120, skin warm, dry, CBG 40mdL.

Outline your prehospital care of this patient.

You are unable to obtain an IV on her what will you do now. ALS is 45 minutes away.

Explain why glucagon may not work for this patient.

Creat drug cards for the following: include the class, mechanism of action, contraindications/cautions, interactions, adverse reactions of the following:

a)  Naloxone hydrochloride

b)  Hypertonic glucose

c)  Glucagon

What are you specifically looking for during a focused physical of a patient with altered mental status?

Face

Eyes/pupils

Nose/Mouth

Respiratory or

Cardiovascular

Vital signs

Matching: write the letter of the diabetic emergency next to the sign or symptom associated with it.

A.  Diabetic ketoacidosis (DKA)

B.  Hypoglycemia

C.  Either DKA or hypoglycemia

___ Patient stopped taking insulin

___ Patient exercised 4 hours ago

___ Clammy skin

___ Decreased level of consciousness

___ Deep respirations

___ History of recent illness

___ Hypotension

___ Dry mucous membranes

___ Muscle tremors

___ Intense thirst

___ Dysrhythmias

___ Seizure

List the intracranial causes of AMS

List the extracranial causes of AMS

Briefly describe the main characteristics for each type of seizure below:

Simple-partial seizure/focal-motor seizure:

Complex-partial seizure/psychomotor seizure:

Absence seizure/petit-mal seizure:

Pseudoseizure/hysterical seizure:

Tonic-clonic seizure/grand mal seizure:

You respond to an unconscious patient. You arrive to find a 54 year-old male who is lying supine on the couch with a wet rag on his forehead. His wife stated that she came home from the grocery store and found him on the floor. She states he “didn’t look right” and assisted him to the couch.

A.  List 4 things you would expect to find from a physical assessment that would suggest the patient had a generalized seizure.

B.  List two assessment findings that would suggest he had a syncopal episode.

C.  You provide the patient with oxygen, take a set of vital signs, place him on the monitor, and start an IV. His vital signs supine are: BP 100/60, pulse 100, respirations 16 and unlabored. He is conscious and alert. He answers questions appropriately.

D.  What size IV would you start and what would be your first choice for the site?

E.  He states that he was mowing the lawn when he didn’t feel right and felt nauseated. He had to steady himself as he walked to the house. He got to the living room and “that’s the last I remember.” Your partner hands you the following prescription medications: regular and NPH insulin, carbazepine, and Vasotec.

What additional questions would you ask the patient?

F.  What additional assessments (history and physical) or treatments would you perform at this point?

You are called to a seizure at a residence. A man meets you at the front door and tells you that his wife just had a seizure. He leads you to the living room where you see two children, wide-eyed and upset. The patient is a 32 year-old female who appears to be sleeping on the couch. You introduce yourself loudly to the patient and she opens her eyes for a moment. She mumbles something unintelligible and goes back to sleep. Her respiratory rate is 16 and her effort is unlabored, except for an occasional sigh. Her radial pulse is strong and regular, at 106. Her pupils are equal and reactive, but sluggish, to light. CBG is 100 and her ECG is a sinus tachycardia.

Her husband states that she has a long standing history of epilepsy and takes Dilantin. She normally takes it three times a day, but ran out last night. They were getting ready to get the refill when she began to seize. Usually her epilepsy is well controlled and she has not had a seizure in 3-4 months. He describes the episode as tonic-clonic which lasted for 2 minutes (this is typical for her). She has no other health problems and overall she is in good health. She is allergic to codeine and Dilantin is her only medication.

After several minutes with oxygen, the patient wakes up and is able to converse with you. She appears very tired, but is alert and oriented x 4. She even makes a joke when you ask her who the president is. She tells you that she does not want to go to the hospital and will sign whatever paperwork you have.

A.  Describe why she had a seizure, especially when her epilepsy has been under control.

B.  Does she need to go to the hospital? Why or why not?

You are called to an overdose. You arrive shortly after the police department. Her friend meets you at the door and advises you that Gloria, a 25 year-old female took “about 20 pills” of Xanax about an hour ago. You notice that the patient is very hostile toward you and is not willing to answer your questions. Her vital signs are BP 122/70, HR 100, respirations of 14, conscious, alert, and oriented x 4. She is slurring her words. List 3 areas where you would search for additional pill bottles.

A.  You also notice an empty bottle of secobarbital. What are the drug classes for secobarbital and Xanax? What are the toxic effects of these drugs when a person overdoses on them?

B.  Do you think that both drugs have been fully absorbed? What factors would speed up absorption of these drugs?

C.  What signs and symptoms would you expect when these drugs are at or above therapeutic levels? How would you manage them?

D.  List your treatments for this patient.

For the chart below, fill in the appropriate assessment findings for each category of altered mental status.

Postictal state of a tonic-clonic seizure

Overdose with a CNS depressant medication

Syncope

General Appearance

Speech

Skin

Posture/Gait

Thought

Memory

Vital Signs

Focused Physical

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