This patient presents to the Emergency Department with altered mental status and fever. Altered mental status can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more. The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination. One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”. The table below outlines this mnemonic.
This patient has confusion, fever, lower abdominal pain, dysuria, and no focal neurological deficits on exam. Diabetic ketoacidosis (Choice A) is unlikely as the patient does not have marked hyperglycemia (>250mg/dL (13.8mmol/L)), polyuria, or polydipsia. Intracranial hemorrhage (Choice C) is unlikely as the patient has no headache, history of trauma, focal neurologic deficits, or coma. Severe hypothyroidism (Choice D), known as myxedema coma, can cause altered mental status. This condition is marked by somnolence or coma, hypothermia, nonpitting edema on the hands and feet, dry skin, macroglossia (enlarged tongue), and hair loss. This patient does not have symptoms consistent with severe hypothyroidism.
Sepsis (Choice B), especially in elderly individuals, can cause altered mental status. The patient’s fever, confusion, lower abdominal pain, and dysuria all point to a likely diagnosis of urosepsis. Sepsis is the most likely cause of this patient’s disoriented state. Treatment with early IV hydration and antibiotics will help remedy the patient’s altered mental status. Correct Answer: B
Joey Ciano, DO, MPH is an Emergency Medicine Physician from New York, USA. He completed his Emergency Medicine Residency in Brooklyn, NY and a Fellowship in Global Emergency Medicine in the Northwell-LIJ Health System. He is interested in building the educational infrastructure of EM in countries where EM is not yet recognized as a field and in countries that are in the early stages of this process. He has partnered with international NGOs in EM educational projects and works as a visiting EM faculty member in West Bengal, India. He is excited to collaborate with the other authors of the iEM Education Project to contribute to world of FOAM-ed.
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