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Z Year3 Clinical Presentations > Confusion > Flashcards

Confusion Flashcards

1
Q

What syndromes can cause a patient to appear confused?

A
  1. Delirium
  2. Dementia
  3. Mental Impairment
  4. Psychosis
  5. Receptive dysphasia
  6. Expressive dysphasia
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2
Q

What is delirium?

A

an acute impairment in cognitive ability together with impaired consciousness

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3
Q

What is dementia?

A

a chronic, progressive impairment in cognitive ability but with intact consciousness - you cannot diagnose dementia from a single mental status assessment

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4
Q

What is dementia?

A

a chronic, progressive impairment in cognitive ability but with intact consciousness - you cannot diagnose dementia from a single mental status assessment

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5
Q

What is mental impairment?

A

a permanent impairment in cognitive ability

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6
Q

What is psychosis?

A

the patient may not be confused, but have a disorder of thought content/perception (e.g. delusions and/or hallucinations)

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7
Q

What is receptive dysphasia?

A

the patient may have difficulties comprehending your questions (e.g. due to damage to Wernicke’s area of the brain)

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8
Q

What is expressive dysphasia?

A

the patient may be cognitively intact but have difficulties verbalizing an answer to your questions (e.g. damage to Broca’s area of the brain)

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9
Q

Can these conditions coexist?

A

yes

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10
Q

After ABCs before taking a history what should you ask for someone with confusion?

A
  1. Are they orientated to time, place and person? Can they tell you why they are here?
  2. Can they follow a three-step command? Can they name three common objects?
    1. Other symptoms: in pain?
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11
Q

How can you tell if they are orientated in time and place? What tests can you use?

A
  1. AMTS is 10q screening tool for assessing confusion: score less than 6/10 indicates cognitive impairment
  2. MMSE score of less than 26/30 indicates cognitive impariement
  3. CAM and MoCA other option
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12
Q

What does the 3 step command test for?

A

receptive and expressive dysphasia

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13
Q

What other symptoms would you enquire about?

A
  • breathlessness
  • cough
  • urinary symptoms
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14
Q

What infections can cause confusion?

A

chest and UTI

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15
Q

If you can get a collatoral history what is important to check?

A
  1. Normal state
  2. Time course
  3. Drugs history
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16
Q

What would acute confusion suggest?

A

delirium over dementia

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17
Q

What would fluctuating confusion suggest?

A

delirium

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18
Q

What is important to check in drugs history?

A

both introduction and cessation of drugs can cause confusion esp in elderly who may have dementia / or on lots of medications some of which may have changed recently

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19
Q

What are the possible infectious causes of confusion?

A
  1. chest
  2. urinary
  3. encephalitis
  4. brain abcess
  5. sepsis
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20
Q

What are the possible neoplastic causes of confusion?

A

brain tumour

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21
Q

What are the vascular causes of confusion?

A
  1. stoke

2. MI causing hypoperfusion

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22
Q

What are the immune causes of confusion?

A
  1. neuropsychiatric lupus

2. Hasimoto’s encephalopathy

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23
Q

What are the trauma causes of confusion?

A
  1. subdural haematoma

2. extradural haematoma

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24
Q

What are the endocrine causes of confusion?

A
  1. hypothyroidism
  2. hyperthyroidism
  3. diabetic ketoacidosis
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25
Q

What are the drug causes of confusion?

A

intoxication or withdrawal of alcohol, opiates, or psychiatric medication or use of diuretics, digoxin, thyroid medication) Drug toxicity accounts for 30% of delirium

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26
Q

What are the metabolic causes of confusion?

A
  1. hypoxia
  2. hypercapnia
  3. hypoglycaemia
  4. hypercalcaemia
  5. sodium or other electrolyte imbalances
  6. thiamine
  7. folate, Vitamin B12 deficiencency
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27
Q

What are the degeneritive causes of confusion?

A

chronic and not cause delirium but will predispose patients to becoming delirious

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28
Q

What vital signs need to be taken in confusion?

A
  1. Pulse and resp rate
  2. BP
  3. Oxygen sat
  4. Temp
  5. Blood glucose
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29
Q

Why do you take pulse and resp rate in confusion?

A

tachycardia or tachypnoea could occur secondary to infection

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30
Q

Why do you measure BP in confusion?

A
  1. hypoperfusion of the brain (due to systemic hypotension) decreases patient consciousness 2. if hypertension and bradycardia is Cushing response indicative of raised ICP
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31
Q

Why do you take oxygen sats in confusion?

A

hypoxia also affects consciousness

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32
Q

Why do you take temperature in confusion?

A

fever may indicate underlying infective process and hypothermia also causes confusion

33
Q

Why do you measure blood glucose in confusion?

A

hypoglycaemia or hyperglycaemia can depress consciousness

34
Q

What happens with T1 diabetes confusion?

A

T1 hyperglycaemia assoicated with ketoacdisosis

35
Q

What happens in T2 diabetes confusion?

A

T2 extreme hyperglycaemia may indicate hyperosmolar hyperglycaemic syndrome (HHS)

36
Q

What do you look for on examination of patient with confusion?

A
  1. Conciousness
  2. Septic focus
  3. Pupils
  4. Focal neurological sings
  5. Needle track signs
  6. Asterixs (metabolic flap)
  7. Breath (for alcohol)
  8. Bitten tongue and/or posterior shoulder dislocation
37
Q

How do you assess consciousness?

A

GCS (allows you to track progress as well)

38
Q

What do you look for on the chest with septic focus?

A

Infection:

  • dull percussion
  • bronchial breathing crackles
39
Q

What do you look for on the urine with septic focus?

A
  • check for suprapubic tenderness -atheter bag check if urine is cloudy
  • peform urine analysis
  • send off specimen for MC&S
40
Q

What do you look for on the cellulitis with septic focus?

A
  • in between toes of diabetics and skin

- check venous or arterial lines that may be focus for infection

41
Q

What do you look for on the cellulitis with septic focus?

A
  • in between toes of diabetics and skin

- check venous or arterial lines that may be focus for infection

42
Q

What do you look for on the cellulitis with septic focus?

A
  • in between toes of diabetics and skin

- check venous or arterial lines that may be focus for infection

42
Q

What do you look for on the cellulitis with septic focus?

A
  • in between toes of diabetics and skin

- check venous or arterial lines that may be focus for infection

43
Q

What do you look for on the meningitis with septic focus?

A
  • neck stiffness
  • photophobia
  • purpuric rash (suggestive of meningococcal septicaemia)
44
Q

What do you look for on the meningitis with septic focus?

A
  • neck stiffness
  • photophobia
  • purpuric rash (suggestive of meningococcal septicaemia)
45
Q

What do you look for in the pupils?

A
  • symmetry
  • size
  • direct and consensual response to light
46
Q

What does it mean if the pupils are dilated and sluggish to react?

A

drug overdose (cocaine, tricyclic antidepressant, severe hypoxia, hypothermia, postical)

47
Q

What can it means if the pupils are assymetrical?

A
  1. normal variant (anisocoria)

2. rarely suggestive of coning secondary to raised ICP or 3rd nerve palsy)

48
Q

What are the focal neurological signs you look for in confusion?

A
  • signs suggestive of stroke or SOL
  • dysphasia
  • visual field deficits
  • nystagmus
  • tone and reflex symmetry
  • plantar responses
  • focal weakness
  • ataxia
  • sensory or visual inattention
49
Q

What would needle track marks suggest?

A

suggestive of IV drug abuse

50
Q

What would asterixis (metabolic flap) suggest?

A
  • hypercapnia
  • hepatic encaphalopathy
  • ureamia
51
Q

What would a bitten tongue and/or posterior shoulder dislocation?

A

suggest convulsive seizure

52
Q

What do you measure in the septic screen?

A
  1. FBC
  2. CRP
  3. Blood cultures
  4. Urine analysis
  5. Urine MC&S
  6. Chest radiograph
53
Q

What do you look at in the FBC for a septic screen?

A
  • WCC elevated in systemic infection

- Anaemia can contribute to hypoxia

54
Q

What would CRP be in the septic screen?

A

elevated: inflammatory but non-specific

55
Q

Why do you get blood cultures in a septic screen?

A
  • Check infection and identify organism and its sensitivity to antibitoics
  • Time consuming
56
Q

What sort of sample do you get for urine analysis?

A

MSU

57
Q

What urine analysis is suggestive of UTI?

A
  • positive leucocyte esterase

- positive nitrate

58
Q

What urine analysis is suggestive of diabetic ketoacidosis?

A
  • positive glucose

- ketones

59
Q

What is seen in a chest x ray with a chest infection?

A

consolidation

60
Q

What is seen in a chest x ray with a chest infection?

A

consolidation

61
Q

What would be seen on a chest x ray with heart failure (could be cause of cerebral hypoperfusion)?

A

enlarged heart

62
Q

What do you measure on the metabolic screen for confusion?

A
  1. Blood gas
  2. U+Es+Calcium
  3. TFTs
  4. Liver enzymes
  5. Thiamine, folate and vitamin B12 levels
63
Q

Why do you take a blood gas?

A

provide info about hypercapnia and acid base balance

64
Q

What can cause metabolic acidosis?

A
  • uraemia
  • diabetic ketoacidosis
  • some toxins
65
Q

When do you do a venous gas?

A

if patient not hypoxic on oxygen sat monitoring or drowsy with hypercapnia a possible cause

66
Q

Why do you measure U+E+Calcium?

A

-Low sodium
-High calcium
-Uraemia
in renal failure can lead to acute confusional state

67
Q

Why would you do TFTs?

A

if clinical signs or history suggests hypo- or hyperthyroidism, should investigate T3/T4 and TSH levels

68
Q

Why do you measure liver enzymes?

A

-liver failure can result in hepatic encephalopathy and suggested by deranged liver enzyme

69
Q

Why do you measure liver enzymes?

A

-liver failure can result in hepatic encephalopathy and suggested by deranged liver enzyme

70
Q

What raised liver enzyme can suggest alcohol abuse?

A

GGY

71
Q

When do you do thiamine, folate and vitamin B12 levels with confusion?

A

if you suspect patient is malnourished (homeless, alcohol or drug abuser, elderly patient living alone who appears cachexic) look for these deficiencies as these are treatable

72
Q

What other tests can you do in confusion?

A
  • toxicology screen

- ECG

73
Q

Why is a toxicology screen not great?

A

only for specific drugs and do not say when taken etc

74
Q

Why do you do an ECG with confusion?

A

to exclude ischaemia or arrhythmia leading to a low-output state and hypoperfusion

75
Q

How do you manage UTI acutely?

A
  1. ABC
  2. Antibiotics
  3. Confusion management
76
Q

What is the confusion management?

A
  1. Don’t leave unatteneded
  2. Put in quiet side room
  3. Make sure have glasses hearing aids that work
  4. Discontinue non-essential medication as may be contributing
  5. Promote good sleep hygiene
  6. Fluid and nutrition - if suspect thiamine deficiency secondary to malnutrition or alcoholism must treat asap
  7. Sedation (LAST resort as can exacerbate confusional state)
77
Q

What medications can you use for sedation?

A
  1. Haloperidol: (30-60 mins to work and can have extrapyramidal side effects so use in caution with Parkinson’s or Lewy body dementia)
  2. Lorazepam: (5-10 mins to act) and useful in restoring sleep

Z Year3 Clinical Presentations (37 decks)

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