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YEAR 3: Oxford Clinical Cases > Confusion > Flashcards

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
Q

List some reasons why post-operative patients may be confused.

A 
Hypoxia
Opiates 
Deranged electrolytes 
Infection
Sleep loss 
Alcohol withdrawal
26
Q

Give four reasons why post-operative patients may be hypoxic.

A

PE
Basal atelectasis
Opiates causing respiratory depression
Anaemia from blood loss

27
Q

Give two reasons why surgery can lead to derangement of electrolytes.

A

IV fluids

Renal failure caused by hypoperfusion

28
Q

What is lithium used to treat? Why is it important to check serum lithium levels?

A

Bipolar disorder

It has a narrow therapeutic window and high serum lithium levels can cause confusion

29
Q

Describe the results of a lumbar puncture in a patient with meningococcal meningitis.

A

High WCC
Gram-negative intracellular diplococci
High protein
CSF: blood glucose ratio < 0.5

30
Q

What is pseudohyponatraemia and what can it be caused by?

A

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
Q

List three causes of hyponatraemia associated with hypovolaemia

A

Diarrhoea
Vomiting
Diuretics

32
Q

List three causes of hyponatraemia associated with euvolaemia

A

SIADH
Hypothyroidism
Adrenal insufficiency (can also be in the hypovolaemic category)

33
Q

List three causes of hyponatraemia associated with hypervolaemia

A

Cirrhosis
Cardiac failure
Nephrotic syndrome

34
Q

List some signs and symptoms of diabetic ketoacidosis.

A

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
Q

Describe features of opiate overdose

A

‘Chill out’
Pinpoint pupils
Respiratory depression
Check for needle track marks

36
Q

Describe features of cocaine overdose

A 
‘Buzz’
Dilated pupils 
Sinus tachycardia
Hypertension 
Pyrexia
37
Q

Describe features of TCA overdose

A

Exert both sympathetic and parasympathetic effects
Sympathetic: dilated pupils, sinus tachycardia, brisk reflexes, and urinary retention
Parasympathetic: dry mouth, drowsiness

38
Q

What triad of symptoms is associated with Wernicke’s encephalopathy?

A

Confusion
Ataxia
Ophthalmoplegia

39
Q

What are the two main symptoms of Korsakoff syndrome?

A

Amnesia

Confabulation

YEAR 3: Oxford Clinical Cases (28 decks)

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