Confusion Flashcards

1
Q

Define delirium.

A

An acute impairment in cognitive ability with impaired consciousness

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2
Q

Define dementia.

A

A chronic, progressive impairment in cognitive ability but with intact consciousness

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3
Q

Define psychosis.

A

A disorder of thought content/perceptions (e.g. delusions and hallucinations)
NOTE: the patient may NOT be confused

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4
Q

Define receptive dysphasia.

A

The patient may be cognitively intact but they have difficulty comprehending speech
Due to damage to Wernicke’s area

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5
Q

Define expressive dysphasia.

A

The patient may be cognitively intact but have difficulty verbalising answers to questions
Due to damage to Broca’s area

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6
Q

What are two important methods of screening confused patients?

A

Are they oriented in time, space and person? Can they tell you why they are there?
Can they follow a three-step command? Can they identify three common objects?

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7
Q

What abbreviated mental test score would indicate that the patient has a cognitive impairment?

A

< 6/10

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8
Q

What MMSE score would indicate that the patient has a cognitive impairment?

A

< 26/30

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9
Q

What does three-step command and naming three common objects test?

A

Three-step command – tests for receptive dysphasia

Three common objects – tests for expressive dysphasia

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10
Q

If the confused patient has been accompanied by a friend/relative, what are some important details to ascertain?

A
The patient’s normal state 
Time course of confusion (acute onset is more likely to be delirium)
Drug history (including alcohol) 
NOTE: a fluctuating course is suggestive of delirium
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11
Q

What are the five most important and common causes of confusion?

A

Chest infection
UTI
Subdural haematoma
Drugs – diuretics, digoxin, thyroid medication
Sodium and other electrolyte abnormalities

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12
Q

Using the surgical sieve, list some other causes of confusion.

A

Infection – encephalitis, brain abscess, sepsis
Neoplastic – brain tumour
Vascular – stroke, MI causing hypoperfusion
Immune/Inflammatory – neuropsychiatric lupus, Hashimoto’s encephalopathy
Trauma – extradural haematoma
Endocrine – hypothyroidism, hyperthyroidism, DKA
Drugs – intoxication or withdrawal from alcohol, opiates or psychiatric medications
Metabolic – hypoxia, hypercapnia, hypoglycaemia, hypercalcaemia, thiamine/folate/B12 deficiencies
Degenerative

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13
Q
Explain the importance of checking the following vital signs in a confused patient:
PR + RR
BP
Sats
Temp
BG
A

Pulse and Respiratory Rate
Tachycardia and tachypnea indicates infective process
Blood Pressure
Hypotension can lead to hypoperfusion of the brain  impaired consciousness
Cushing’s response (to raised ICP): high BP + low HR + irregular breathing
Oxygen Saturation
Hypoxia impairs consciousness
Temperature
Fever indicates infection
Hypothermia can cause confusion in elderly patients
Blood Glucose
Hypoglycaemia and hyperglycaemia can depress consciousness
T1DM: hyperglycaemia may be associated with DKA
T2DM: extreme hyperglycaemia may indicate hyperosmolar hyperglycaemia state (HHS)

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14
Q

List some key features of examination of a confused patient.

A
Consciousness
Septic focus 
Pupils 
Focal neurological signs 
Needle track marks 
Asterixis 
Breath
Bitten tongue and posterior shoulder dislocation
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15
Q

Describe some pathological variations in the pupils of a confused patient.

A

Pinpoint + sluggish to react = opiate or barbiturate overdose
Dilated + sluggish to react = drug overdose (e.g. cocaine or TCA), severe hypoxia, hypothermia, post-ictal
Asymmetrical = could be normal variant (anisocoria), but is rarely suggestive of coning secondary to raised ICP

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16
Q

What would a bitten tongue or a posterior shoulder dislocation suggest?

A

Convulsive seizure

17
Q

What are the three divisions of the Glasgow Coma Scale and how many points are allocated to each?

A
Eyes = 4 
Verbal = 5
Motor = 6
18
Q

Which investigations would be performed to find out whether an infection is the cause of the confusion?

A

FBC – raised WCC
CRP – raised in infection
Blood cultures
Urinalysis – check for features of UTI (leucocyte esterase + nitrites), or DKA (positive glucose + positive ketones)
Urine MC&S
Chest radiograph (check for consolidation caused by chest infection)

19
Q

Which investigations would be performed in a metabolic screen?

A

Blood gas – check hypercapnia, acid-base balance
U&Es – check for electrolyte imbalances
TFTs
Liver Enzymes – hepatic encephalopathy can cause confusion
Thiamine, folate and B12 levels – check whether the patient is malnourished

20
Q

What does disproportionately raised GGT suggest?

A

Alcohol abuse

21
Q

Why is it important to perform an ECG in a confused patient?

A

Exclude ischaemia and arrhythmia that could lead to a low-output state causing hypoperfusion of the brain

22
Q

Describe the management of a confused patient.

A

Resuscitation – assess ABC
Antibiotics – if there is an infectious cause
Conservative measures
Make sure the patient isn’t left unattended
Keep them in a quiet side room if possible
Discontinue non-essential medications
Promote good sleep
Consider providing fluids and nutrition if they are unable or unwilling to maintain a good diet

23
Q

Which sedatives may be used if a confused patient requires sedation?

A

Haloperidol

Lorazepam

24
Q

Describe the management of a patient in alcohol withdrawal.

A

Thiamine is important because it can prevent Wernicke’s encephalopathy
Chlordiazepoxide reduces the symptoms of withdrawal
NOTE: alcohol withdrawal is a medical emergency

25
List some reasons why post-operative patients may be confused.
``` Hypoxia Opiates Deranged electrolytes Infection Sleep loss Alcohol withdrawal ```
26
Give four reasons why post-operative patients may be hypoxic.
PE Basal atelectasis Opiates causing respiratory depression Anaemia from blood loss
27
Give two reasons why surgery can lead to derangement of electrolytes.
IV fluids | Renal failure caused by hypoperfusion
28
What is lithium used to treat? Why is it important to check serum lithium levels?
Bipolar disorder | It has a narrow therapeutic window and high serum lithium levels can cause confusion
29
Describe the results of a lumbar puncture in a patient with meningococcal meningitis.
High WCC Gram-positive intracellular diplococci High protein CSF: blood glucose ratio < 0.5
30
What is pseudohyponatraemia and what can it be caused by?
This is an artifact produced by the machine that analysis U&Es in which sodium appears low although it is normal If sodium is low, plasma osmolality should also be low Causes of pseudohyponatraemia: Hyperproteinaemia Hyperlipidaemia Hyperglycaemia/mannitol/glycine (associated with HIGH plasma osmolality)
31
List three causes of hyponatraemia associated with hypovolaemia
Diarrhoea Vomiting Diuretics
32
List three causes of hyponatraemia associated with euvolaemia
SIADH Hypothyroidism Adrenal insufficiency (can also be in the hypovolaemic category)
33
List three causes of hyponatraemia associated with hypervolaemia
Cirrhosis Cardiac failure Nephrotic syndrome
34
List some signs and symptoms of diabetic ketoacidosis.
Polyuria, polydipsia Decreased mental state due to hyperglycaemia Nausea/vomiting Abdominal pain Shortness of breath or Kussmaul breathing Hypotension and tachycardia due to dehydration Ketotic (fruity) breath
35
Describe features of opiate overdose
‘Chill out’ Pinpoint pupils Respiratory depression Check for needle track marks
36
Describe features of cocaine overdose
``` ‘Buzz’ Dilated pupils Sinus tachycardia Hypotension Pyrexia ```
37
Describe features of TCA overdose
Exert both sympathetic and parasympathetic effects Sympathetic: dilated pupils, sinus tachycardia, brisk reflexes, and urinary retention Parasympathetic: dry mouth, drowsiness
38
What triad of symptoms is associated with Wernicke’s encephalopathy?
Confusion Ataxia Ophthalmoplegia
39
What are the two main symptoms of Korsakoff syndrome?
Amnesia | Confabulation