An Approach to Altered Mental Status (e.g. delirium)

[@jeffsuchard720]

Great video, Eric. Note: There is no requirement to obtain arterial blood for co-oximetry if carbon monoxide poisoning is suspected; a venous blood sample will give reliable results.

[@StrongMed]

Ugh. I can't believe I said that. Thanks for the correction Jeff! (EDIT: Successfully edited out the mistake!)

[@tret5r]

@david Soto have you supported him on patreon ?

[@SBellaba]

Excellent video! This series of videos should be much more popular among junior doctors. Keep it up Dr Strong.

[@mwelch94]

Did you just read my mind? I was literally looking through your videos looking for an altered mental status lecture and this came out 10 minutes later 😂

[@agd712]

Literally the best medical playlist on youtube. Bravo man! These should do me well during intern year. Please add to that playlist as well!

[@Ch3mG33k]

Your students are lucky to have ya. Your lectures never cease to amaze from a pedagogical standpoint. The information is so incredibly clear, rationally presented, and "complete." I discovered you first for your great ECG videos and have been burning through the rest of your vids since.

[@StrongMed]

Thank you for the kind words!

[@AlienAngel543]

Thank you very much Dr Strong, you are such a great teacher. I hope to be mentored by you. So that I can also become an excellent physician and teacher like yourself. ❤ from Nigeria.

[@stoicable6174]

My god, this is the best lecture I've come across.

[@nickgowen7737]

Great video as always! I'm very happy to have this resource, as I love giving trainees the CPSolvers AMS MIST schema but I always cringe a bit when calling it "AMS." I appreciate you taking the time explain all the nuances. I also really like your algorithm at the end. I very rarely end up needing LP in that second step area, but you're absolutely right that we must think of it there every time. And I've had many cases in which we didn't do the LP initially because meningitis was unlikely, but then did do one in the later steps as diagnosis remained elusive and autoimmune encephalitis became more likely. You allude to this in multiple places, but I've found that if the initial H and P and labs are unrevealing, probably somewhere in the range of 2/3 of patients spontaneously recover with euvolemia maintenance and 24-48 hours of observation. I assume most of these are medication-induced and a few are other transient illnesses like viruses, but obviously I never really know.

[@StrongMed]

Thanks Nick! I appreciate your last point very much, and I probably should have explicitly discussed it. My experience is also that patients lacking a diagnosis frequently recover spontaneously, and agree that many are probably medication induced. I've had 2-3 patients over the years spontaneously clear and afterwards admit that they had been using some substance that routine tox screens don't include (e.g. bath salts).

[@lennartemann6734]

Again a brilliant video thank you for your incredible amount of work, knowledge and skills you are putting into those videos

[@Plinktitioner]

As always, thank you for the videos you produce. They are always so helpful and insightful.

[@jrblankenship88]

This is a fantastic video. I’m a paramedic in the prehospital setting. I’m always trying to learn, and revisit assessment for patients like this.

[@sunving]

Thank you Doctor Strong, wonderful lecture for real, I listen to this many time in my life but still yours is one of the great lecture. I thank you very much , I shall listen to this again one more time .

[@KP_Medicine]

Beautiful and easy to get along. Thanks Dr. Eric!!

[@Somaye40]

Comprehensive and helpful. Thank you.

[@jakewong6943]

Thank you Dr. Strong! I noticed many pathologies here are also listed in your video Approach to Seizures. For these (ex. ischemic stroke, hemorrhage, hypoxemia, hypocalcemia, etc), is it possible to generalize and say whether altered mental status or a seizure would be more predictive of the severity of the underlying pathology?

[@StrongMed]

As an extremely general rule, etiologies for new onset seizure in adulthood are more dangerous than those for altered mental status. Or put another way, there are plenty of relatively benign, easily correctable causes of altered mental status, but most of the common causes of new onset seizures are life-threatening - either imminently (e.g. hypoglycemia, alcohol withdrawal, encephalitis) or in the long-term (e.g. brain tumor). There is also a shorter list of causes of seizure. So if seeing a patient who was presenting with both AMS and seizures, I would think primarily about the seizure diagnostic framework and work-up.

[@mickeysingh7443]

sir too much respect for your teaching

[@MossyMozart]

When I had what the immunologist thinks was a viral meningitis, I was way beyond confused; I was delirious. After my partner revived me and picked me up off the floor and called an ambulance, I tried to put a tissue box on my foot because I was convinced it was my shoe. I don't remember anything for about 2 days, EXCEPT for a spinal tap - I recall that clearly.

[@moradzayed]

really great lecture thank you for the excellent work

[@danieldevaprasad2254]

Beautiful lecture

[@kitsana1840]

great lecture, as a General practitioner who has less time to taking a note. could you please upload the slide for taking note pls ? that would be perfect sir

[@SandraAnnEvans]

My husband had open heart surgery in September. We found that he contracted a "staph" infection in the incision. He had to have a debreadment and removal of part of his sternum, plastic surgery to cover the gaping hole they created, and then spinal surgery to remove a puss sack created by "Staphylococcus DermaTitus." He was on Vincomycin for 4 weeks, then they switched it to Daptomycin and he is still taking it. I can't describe his mental condition . . . He is alert; but, something is wrong. The doctors at Kaiser told us he was in "delerium?" I can't tell what is going on or how long it will last? Does anyone have any suggestions? He was a highly independent successful software developer for a 3D x-ray microscope company. I don't know what to do and Kaiser is a DEAD END . . . Will he recover? We have been living in a nightmare for months now. THANK YOU FOR THE INFORMATIVE VIDEO!

[@ZainabTriesYoutube]

Please make a video on paraneoplastic syndromes and to work up and approach to them

[@yassinefenn3915]

Hello professor, Am I allowed to screenshot your work-up maps and diagrams... To include it in a small pdf file for educational and non-commercial personnal and collective use [With Credits to your channel and the video's title of course]

[@StrongMed]

As long as it is for non-commercial purposes and credit is provided somewhere, you are more than welcome to distribute it!

[@yassinefenn3915]

@@StrongMed Thank you

[@jasminemalthy]

Thanku sir for such a great video, it was a great help. Pls guide us with more videos.

[@StrongMed]

I'm glad the videos have been helpful! I post them as fast as I can make them.

[@kaze123ckr]

Orientation seems to be part of alertness ? (Alertness: awareness of themselves and others around them) What's the difference?

[@cavindor2423]

Hello.I love your channel doc.

[@ΆγιοςΧίλαριος]

Thanks for the great vid. I have a few questions: can Wilson disease cause "AMS" without acute hepatic failure? . Can hypothermia per se cause "AMS"? Should EKG (+/- troponin) be a routine part of workup?. Waiting for EKG vids. ♥️

[@StrongMed]

>Can Wilson disease cause "AMS" without acute hepatic failure? Yes, definitely. Although patient presenting with primarily neurologic features tend have problems like dysarthria, ataxia, and tremor, it can also initially present as AMS. When this happens, it most typically causes problems with concentration, or behavioral/personality changes. >Can hypothermia per se cause "AMS"? Sure, if it's severe enough - but it certainly won't be a diagnostic challenge! Risk of developing somnolence and confusion secondary to hypothermia occurs as body temperature drops below 32C (90F). However, as temperature drops further, cardiac output starts to drop as well, and then whether you say further AMS is caused by hypothermia or by hypothermia-induced cardiogenic shock becomes semantics. www.ncbi.nlm.nih.gov/books/NBK545239/ >Should EKG (+/- troponin) be a routine part of workup? I'm sure almost every patient presenting with AMS has an EKG as a matter of routine, but if there is truly no other reason to get an EKG (e.g. abnormal pulse, hypotension, concurrent chest pain/dyspnea/palpitations, elevated JVP, evidence of shock, etc...), the only diagnosis presenting as AMS that I can immediately think of that an EKG will provide an earlier clue than other tests is TCA overdose (e.g. wide QRS + a distinctively tall and wide R wave in aVR), but that's a bit of a zebra. (EDIT: An EKG could also show the deeply inverted T-waves of a subarachnoid hemorrhage, but no one would act on that without the patient getting a head CT anyway)

[@ΆγιοςΧίλαριος]

@@StrongMed thanks

[@edreesalqutel8002]

Nice work

[@anastasiaaa4094]

sir may i know from where you are taking information, harrison or up-to-date

[@StrongMed]

UpToDate is the most commonly used reference for this series (Approach to Symptoms). I haven't cracked open Harrison's in years! But I also typically read 3-5 review papers on each symptom before making the videos, and will look up more specific papers to clarify things as they come up. And this is combined with years of experience practicing and teaching medicine.

[@anastasiaaa4094]

@@StrongMed Thankyou sir you are amazing!

[@BaoNguyen-fd4vv]

Tramadol is a prodrug where its metabolites work on mu-receptors, should it not be considered as an opioid?

[@StrongMed]

That's a great question! Since opioids are defined based on function, rather than structure, and tramadol (and as you note, one of tramadol's primary metabolites) acts on the mu receptor, one could very reasonably consider it an opioid - and many people do. However, it's opioid action is very weak; it's is an infamously "dirty" drug, with actions not just on mu-receptors, as well as serotonin and norepinephrine pathways (among others). Asking whether tramadol is an opioid feels analogous to whether amiodarone should be considered a beta blocker (amiodarone acts on beta receptors, as well as potassium, calcium, and sodium channels). Interestingly, as someone who entered medical school around the time that tramadol was introduced to the market, there are many more people now who consider it an opioid then did originally. Back in the early 2000s, it was typical for physicians, pharmacists, and yes, drug reps, to refer to tramadol as a totally safe "non-opioid" pain medication to distinguish it from the addictive opiates/opidoids (e.g. morphine, meperidine) - which in retrospect was an error. I think first learning about the drug during that time probably biases where I naturally categorize it. Either way, I don't think I've written a de novo prescription for tramadol in years, and would not recommend it. A great summary of why tramadol is problematic: toxandhound.com/toxhound/tramadont/ tl;dr: Yes, you are probably right, but I first learned about the drug when pharm reps misled us about its pharmacology. Regardless, don't prescribe it.

[@edreesalqutel8002]

ممتاز جدا جدا

[@MuhammadAhsan-mp8hq]

Tough topic

[@hosneyamr5538]

I find glasgow coma scale usualy not helpfull in medical causes of altered mental status and it's rather more usefull with trauma patients

[@StrongMed]

Agreed. Also see it used sometimes in neurosurgical catastrophes.

[@dailydoseofmedicinee]

👐👏

[@MonaSax-ir6cw]

Where does ADHD fall?

[@StrongMed]

It falls outside of this paradigm, which is focused on acute and subacute changes in mental status, not chronic or episodic changes. In addition, the changes in concentration and attention which can be attributed to ADHD - while non-trivial - are less pronounced than in the conditions covered in this video.

[@gabrielsticks2829]

10 mg iv Diazepam is the best answer

[@HockeyGuy_in_STL]

I watched almost the whole video but now I have forgotten most of what I heard and I am feeling kind of sleepy and I think I smell pizza, too . . .

[@Runeman40055]

Are you a doctor ?

[@StrongMed]

Yes, I'm a hospitalist (internist who specializes in the care of hospitalized patients, and a clinical associate professor at Stanford medical school.

[@Runeman40055]

@@StrongMed you’re internal medicine attending physician ?

[@StrongMed]

@@Runeman40055 Yes.