Chapter 17 - Confusion

Question 1

What is confusion (Rosen’s) and what can it represent as in a patient?

Answer 1

Confusion may present processes impacting:

• memory
• attention
• awareness

Confusion is a symptom (not diagnosis). Recent change in behaviour

Spectrum:

1) mild impairment of short term memory toooo
2) delirium - global inability to relate to environment and process sensory

With confusion: it’s about the content of cortical function - categories that affect normal cortical function

1) Substrate deficiency
- hypoxia
- hypoglycemia

2) Neurotransmitter dysfunction
- endocrine disease
- hepatic failure
- CNS sedatives
- EtOH
- Poisons

3) Circulatory dysfunction
- shock (i.e. if you are not perfusing your brain - you are not getting oxygen or glucose to your brain)

Question 2

List the major categories for the differential diagnosis of confusion?

Answer 2

1) Primary intracranial disease
2) Systemic disease secondarily affecting the central nervous system
3) exogenous toxins
4) drug withdrawal

DIMES approach
Can use DIMES approach for confusion, seizures, AMS, confusion, syncope etc)

Question 3

Differentiate between organic and functional (psychiatric)confusion?

Answer 3

Hx:
1)Onset: hour-to days (organic) vs. weeks to months (functional)

MSE:

1) fluctuating LOC (organic) vs. alert (functional)
2) disoriented (organic) vs. oriented (functional)
3) attention disturbances (organic) vs. agitated, anxious (functional)
4) Visual Hallucinations (organic) vs. auditory hallucinations (functional)

PE:

1) abnormal vital signs (organic) vs. normal VS (functional)
2) nystagmus (organic) vs. no nystagmus |(functional)
3) focal neurologic signs (organic) vs. Purposeful movement (functional)
4) signs of trauma (organic) vs. no trauma (functional)

ORGANIC UNTIL PROVEN OTHERWISE

Question 4

List 3 critical emergent causes of confusion

Answer 4

Critical causes (those that may cause shock) - HYPER

1) shock
2) hypoxia
3) hypotensive
4) head infections
5) hypertensive encephalopathy
6) head exploding

Emergent

1) anemia - profound that can lead to diffuse ischemia
2) metabolic
3) electrolyte
4) hepatic encephalopathy/failure
5) nutrition
6) sepsis
7) drugs and toxins
8) intracranial (trauma, tumour, infection, stroke, SAH, seizures)

The Hyper Hippo’s H0ead: Hypertensive encephalopathy, hypoglycemia, hypoxia, hypotension, head , tumour stroke SAH seizure etc

Question 5

Describe a quick assessment tool for hte screening of confusion

Answer 5

1) assess AxO
2) repeat a phrase and remember it
3) count backwards from 20 to 1, serial 7’s etc
4) months in reverse
5) repeat memory phrase we talked about above

Question 6

Work up for someone with confusion

Answer 6

1) Full set of vitals with OH
2) glucose
3) CBC, lytes, liver panel, kidney function
4) ECG (MI)
5) urine
6) CXR
7) CT head (maybe ) and LP maybe