Intermittent confusion, altered mental status


• Scene – VS
• En route – VS, IV 20 L ac, 500ml NS at KVO, 12 lead
• Hospital – Not known. Hospital was concerned with patient behavior, assigned a male nurse and notified security.


• Response to treatment – No changes
• Disposition – Not known


PIC- E. Williams Paramedic Partner- Lisa Baubock Paramedic Date 8/24/15


Elliot Williams, Paramedic Woodburn Ambulance


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


• Altered mental status

Differential Diagnosis

• Atypical MI
• CVA/stroke
• Hypoglycemia or hyperglycemia
• Dehydration
• Hypertensive crisis
• Psychiatric emergency
• Substance abuse including EtOH intoxication
• Malingering (diagnosis of exclusion)

Patient Workup History

• Patient states – Patient states he almost fell asleep driving today 3 times, ended up in a yard and almost hit a tree at one point, so he stopped at a good samaritan’s house who had helped him with car problems earlier today.
• This is the person who called 911. He states he doesn’t know the patient at all and he was just trying to help out.
• Extensive medical history including kidney failure, cardiac pacemaker, TIA, hernia. Patient also states constipation so bad he used a coke bottle to give himself an enema.
• Patient states 6/10 pain from hernia and foot pain from walking 10 miles due to car problems.
• Patient is very loquacious, talks about things that do not make sense. This patient feels like a bipolar manic, or borderline personality – some things that he talks about are not based in reality.
• States he doesn’t eat well and hasn’t been drinking much water.
• Denies drugs or alcohol

Physical Exam

• GCS – 15
• EKG – nsr
• CBG – 83
• Feet swollen, skin PWD, white around corners of mouth, superficial cuts on lower legs in various stages of healing.
• Clothes are torn. Otherwise atraumatic and unremarkable.

Editor’s Notes

Patients who are confused can be difficult to manage and have the potential to become agitated and violent. This patient seemed calm and answered many questions appropriately, but his answers seemed to run on and at times tangential. Psychiatric emergencies should be considered but only after a careful review of the patient’s medical history and medications.

-Dr. David Spiro

Suggested References

Acute Altered Mental Status in Elderly Patients
Assessing mental status
Managing psychiatric emergencies


• Gender: Male
• Age: 64 years
• Height: Not Available


• Temperature: Not Available
• Heart Rate: 84
• Respiratory Rate: 16
• Pulse Oximetry: 99% RA
• Blood Pressure: 178/98

Signs and Symptoms

Lethargic; weak; confusion.

History Medical

• PMH: Kidney failure, cardiac, pacemaker, HTN, TIA, hernia.
• Allergies: Multiple including psych meds, Depakote, valium, Risperdal.
• Dispatch info: Lethargic male, caller doesn’t know him, just helped him out.


• Not known. Lives alone.


• Levothyroxine, ASA, metoprolol, hydrocodone

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