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Y3 Oxford Cases > Confusion > Flashcards

Confusion Flashcards

1
Q

What syndromes can make a patient appear confused

A 
Dementia
Delirium 
Psychosis 
Expressive dysphasia
Receptive dysphasia
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2
Q

What questions can you asked someone who presents as confused

A

Are the oriented to time, place, and person?
Can they tell you why they are here? (AMTS)
Can they follow a 3 step command? Can they name 3 common objects?
Are they in pain? Is there breathlessness, cough, or urinary symptoms

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3
Q

What questions can you ask to a confused patient’s accompaniment

A

What their normal state is
If the confusion is sudden or gradually worsening
Drug history (includes alcohol)

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4
Q

What are the categories in the INVITED MD mnemonic surgical sieve and give some examples of each in the context of confusion causes

A

Infectious (chest, UTI, encephalitis, brain abscess, sepsis)
Neoplastic (brain tumour)
Vascular (stroke, MI -> hypoperfusion)
Immune (neuropsychiatric lupus, Hashimoto’s encephalopathy)
Trauma (subdural haematoma, extradural)
Endocrine (hypothyroidism, hyperthyroidism, diabetic ketoacidosis)
Drugs (alcohol, opiates, psychiatric medications, diuretics, digoxin, thyroid medication
Metabolic (hypoxia, hypercapnia, hypoglycaemia, hypercalcaemia, electrolyte imbalance, thiamine/B12/folate deficiency)
Degenerative conditions

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5
Q

What vital signs are important in investigating confusion

A 
Blood pressure
Pulse and resp rate
Oxygen saturation
Temperature
Blood glucose
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6
Q

Why may BP be useful in investigating confusion

A

Hypoperfusion of the brain decreases consciousness

hypertension + bradycardia -> Cushing response to intracranial pressure

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7
Q

Why may pulse and resp rate be useful in investigating confusion

A

Tachycardia or tachypnoea can be secondary to infection

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8
Q

Why may oxygen saturation be useful in investigating confusion

A

hypoxia will affect consciousness

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9
Q

Why may temperature be useful in investigating confusion

A

Fever -> infection

Hypothermia can cause confusion

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10
Q

Why may Blood glucose be useful in investigating confusion

A

Hypoglycaemia or hyeprglycaemia can depress consciousness

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11
Q

What investigations would you do on patients who are difficult to examine (due to confusion)

A 
Consciousness using GCS 
Septic focus 
Pupils
Focal neurological signs
Needle track marks
Asterixis 
Breath 
Bitten tongue
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12
Q

What do you focus on in assessing septic focus

A

Chest
Urine
Cellulitis
Meningitis

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13
Q

What signs would you look for in a chest infection

A

Dull percussion

Bronchial breathing and crackles

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14
Q

What signs would you look for in a urine infection

A

Suprapubic tenderness
Cloudy urine (in catheter bag)
Urinalysis + send specimen for MC&S

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15
Q

What signs would you look for in cellulitis

A

Look at the skin
Pay attention to the feet in diabetics
Check venous or arterial lines

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16
Q

What signs would you look for in meningitis

A

Neck stiffness -> meningism
Photophobia
Purpuric rash (meningococcal septicaemia)

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17
Q

What are the 3 components of GCS

A

Eyes
Motor
Verbal

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18
Q

What are you assessing in the eyes for confusion

A

Pupil symmetri, size, and direct consensual response to light

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19
Q

What causes pupils to become pinpoint

A

Drug overdose (tricyclic anti-depressants, cocaine)
Severe hypoxia
Hypothermia
Postictal

20
Q

What causes pupils to become dilated

A

Opiate or barbiturate overdose

21
Q

What causes asymmetrical pupils

A

anisocoria, can be normal

Suggestive of coning secondary to raised intracranial pressure or 3rd nerve palsy

22
Q

What focal neurological signs do you look for in confusion

A

Dysphasia, visual field defects, nystagmus, tone, reflex symmetry, plantar responses, focal weakness, ataxia and sensory or visual inattention
Suggests stroke or SOL

23
Q

What does asterixis suggest

A

Hypercapnia
Hepatic encephalopathy
Uraemia

24
Q

What do you look for in the breath on investigation

A 
Alcohol
Fetor hepaticus (liver failure)
Uraemic fetor (renal failure)
Fruity breath (ketones in ketoacidosis)
25
What does a bitten tongue suggest
convulsive seizure
26
What does a confusion screen consist of
Septic screen Metabolic screen Toxicology screen ECG
27
What are the positive signs of infection in urine analysis
MSU - +ve leucocyte esterase and nitrites
28
What does glucose and ketones in the urine suggest
Diabetic ketoacidosis
29
Which electrolyte imbalances cause confusion
Low sodium | High calcium
30
What is in a septic screen for confusion
``` FBC CRP Blood cultures Urine analysis Urine MC&S CXR ```
31
What is in the metabolic screen for confusion
``` Blood gas U&Es TFTs Liver enzymes Thiamine Folate B12 ```
32
What in LFTs may suggest alcohol abuse
Raised gamma-glutamyl transferase (GGT)
33
What is the management for confusion
``` Ensure patient is not left unattended Put them in a quiet side room if possible Discontinue non-essential medications Promote good sleep hygiene Fluids and nutrition ```
34
If you are unable calm a confused patient, what are your next steps
Haloperidol - 30-60 minutes (can have extra-pyramidal effects) Lorazepam - 5-10 minutes
35
What does high or normal osmolality with hyponatraemia suggest
Pseudohyponatraemia Low sodium due to artefact High - hyperglycaemia, mannitol, glycine Normal - hyperlipid, hyperprotein
36
What are the causes of hyponatraemia if the patient is hypervolaemic
Congestive cardiac failure Hepatic failure Nephrotic syndrome
37
What are the causes of hyponatraemia if the patient is euvolaemic
High urine osmolality - SIADH | Normal urine - fluid overload, hypothyroidism
38
What are the causes of hyponatraemia if the patient is hypovolaemic
Na loss is renal - Diuretics, renal failure, addisons, pyelonephritis Na loss is not renal - vomiting, diarrhoea, cutaneous loss through sweating and burns, pancreatitis, small bowel obstruction
39
What is the treatment for hypoglycaemia
Conscious - sweet drink or glucose tablets | Unconscious - Dextrose gel, 50 mL 20% glucose / 250ml 10% glucose IV, IM glucagon
40
What are the clinical signs of DKA
Polyuria, polydipsia and reduced mental state (hyperglycaemia) Nausea, vomiting, abdo pain, fatigue, SOB, Kussmaul breathing Hypotension and tachy (dehydration) Ketotic breath
41
How does opiate overdose compare to cocaine overdose
opiates - pinpoint pupils and respiratory depression Cocaine - dilated pupils, sinus tachy, hypotension and pyrexia. May have resp. distress and urinary retention
42
How do tricyclics overdose present
Sympathetic - pupil dilation, tachy, brisk reflex, urinary retention Para - dry mouth and drowsiness
43
What treatment should be given for confusion with Hx of alcohol abuse and why
Thiamine e.g. pabrinex | Prevent Wernicke's encephalopathy -> Korsakoff's syndrome (amnesia and confabulation)
44
What are the indications for immediate CT scan
``` GCS <13 on arrival GCS <15 2h post incident Post traumatic seizure Focal neurological deficit Vomiting > 1 Suspected skull fracture ```
45
What are the criteria for urgent (8h) CT head
Any head injury on warfarin Loss of consciousness or amnesia + >65, fall > 1m or > 5 stairs, pedestrian/bicycle vs vehicle, more than 30mins amnesia before injury

Y3 Oxford Cases (29 decks)

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