Confusion#

Question 1

Define the following:

Dementia
Delirium 
Psychosis
Mental impairment 
Receptive dysphasia
Expressive dysphasia

Answer 1

1. Dementia= chronic, progressive impairment in cognitive ability with INTACT consciousness
2. Delirium= acute impairment in cognitive ability with IMPAIRED consciousness
3. Patient not actually confused, just hallucinating/deluded due to deranged personality and loss of contact with reality
4. Permanent impairment in cognitive ability
5. Difficulties comprehending what you ask (wernicke’s area)
6. Cognitively INTACT but difficulty verbalising answer to question (broca’s)

Question 2

How can you quickly test for receptive and expressive dysphasia

Answer 2

Can they follow a 3 step command (tests receptive dysphasia)

Can they name 3 common objects (tests for expressive dysphasia)

Question 3

What score is concerning on an AMTS

Answer 3

<6/10

Question 4

What does AMTS test

YOU MUST KNOW THIS FOR OSCE!

Answer 4

Orientation in time, place and person

"remember this 33 dorchester street"
TIME: 
-What time is it 
-What year are we in 
-How old are you

SPACE:
-Which building are you in

PERSON:
-Who am I? Who is that person

LONG TERM MEMORY:

• What is your DOB
• What year did the 2nd WW end
• Who is the current prime minister

SHORT TERM MEMORY:

• What street did I tell you about
• Count back from 20 to 1

Question 5

What is an important traumatic cause of confusion

Answer 5

Subdural haematoma

Question 6

Drugs causing confusion?

Answer 6

(e.g. intoxication or withdrawal of alcohol, opiates, or psychiatric medications;
or use of diuretics, digoxin, thyroid medication).

Question 7

What is the cushing response

Answer 7

Hypertension and bradycardia

Indicative of raised ICP

Question 8

Why is temp an important vital sign when looking at confusion

Answer 8

fever may indicate an underlying infective process. Alternatively
hypothermia also causes confusion and is not uncommon in the elderly

Question 9

When might you find i. fixed dilated pupils and ii. fixed constricted pupis

Answer 9

i. fixed dilated= drug overdose e.g. cocaine, TCAs; severe hypoxia; hypothermia; post-ictal (=postictal state is the altered state of consciousness after an epileptic seizure)

Asymmetric pupils suggestive of coning secondary to raised ICP or a 3rd nerve palsy

Question 10

When does “cherry red lips” occur

Answer 10

In carbon monoxide poisoning

Question 11

What can asterixis (metabolic flap) suggest

Answer 11

Hypercapnia, uraemia, hepatic encephalopathy

Question 12

What 2 factors suggest a convulsive seizure

Answer 12

Bitten tongue and/or posterior shoulder dislocation

Question 13

What does a septic screen involve

Answer 13

FBCs, CRP, blood culture, urine dip, urine MC&S, chest radiography

Question 14

Why might chest radiography be useful in patient with confusion

Answer 14

consolidation is seen in a chest infection. An enlarged
heart would be suggestive, although not diagnostic, of heart failure, which
could be the cause of cerebral hypoperfusion

Question 15

What does a metabolic screen involve

Answer 15

ABG, U&Es, thyroid function, liver enzymes, thiamine, folate, vit B12

Question 16

What should you do if you suspect thiamine deficiency secondary to alcohol or malnutrition

Answer 16

You must treat (e.g. with thiamine or
Pabrinex, a cocktail of vitamins). Th iamine defi ciency rapidly causes irreversible cerebral damage and if you wait for the results of your investigations it may already be too late.

Question 17

What is contained in pabrinex

Answer 17

abrinex injections contain the water-soluble vitamins C (ascorbic acid), B1 (thiamine), B2 (riboflavin), B3 (nicotinamide) and B6 (pyridoxine).

Question 18

What drugs might you use as sedation

Answer 18

i. Haloperidol/chlorpromazine (take 30-60 mins to take effect)
EXTRAPYRAMIDAL SIDE EFFECTS (use with caution in Parkinson’s disease patients)

ii. Lorazepam (takes 5-10 minutes) . Useful in restoring sleep, but can worsen confusion and is a respiratory depressant