Altered mental status, previous h/o stroke


• Scene – vitals, O2, monitor, CBG

• En route – IV, 12-lead, vitals

• Hospital – labs


• Response to treatment – none

• Disposition – admitted to hospital for high ammonia level of 136


Eric Boyd, Paramedic Woodburn Ambulance


David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center


• Altered mental status

Differential Diagnosis

• Hepatic encephalopathy



• Myocardial infarction

• Drug overdose

• Hypertensive encephalopathy

• Renal failure

• Electrolyte abnormality

Patient Workup History

• Patient states – nonverbal

• Family states pt went to bed normal and able to perform normal daily activities.

• Pt has been difficult to wake up. She has been in bed all morning and won’t stay awake.

• No recent illness or urinary complaints.

• Family states pt receives multiple transfusions a week (unable to determine why).

• Pt nonverbal and family was unable to give a good Hx.

Physical Exam

• Pt was found prone on her bed. She was responsive to pain and withdrew from stimulation.

• Skin: pink, warm, dry, no jaundice noted

• Eyes: pupils fixed at ~ 4mm, no jaundice noted

• Bilateral breath sounds clear and equal

• Moves all extremities, able to raise arms but not hold them up, no facial droop

• Strong smell of urine and feces; incontinence

• CBG- 142


Editor’s Notes

Altered mental status can have many etiologies in the elderly. In this case, the family was unable to provide a good history for the EMS team. Getting a sense of baseline mental status is key, and an understanding of whether the changes are more acute or chronic in nature.

-Dr. David Spiro


• Gender: Female

• Age: 85 years

• Height: Not Available


• Temperature: 97.3 F/36.3 C

• Blood Pressure: 140/52

• Heart Rate: 66

• Respiratory Rate: 16

• Pulse Oximetry: 99% RA

Signs and Symptoms

Altered mental status

History Medical

• PHM: Skin and bladder cancer, hypertension, diabetes, CVA, liver cirrhosis

• Allergies: Sulfa

• Dispatch info: 85 y/o semi-conscious breathing


• Lives at home with family unknown current alcohol use; able to perform normal daily activities.


• List forwarded to ED

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