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Altered Mental Status
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1. A 69-year-old woman with a past medical history of hyperten- sion, hypercholesterolemia, diabetes mellitus type 1, and alcohol abuse is brought to the emergency department (ED) by her daughter who states that her mom has been acting funny over the last She states that the patient did not know where she was despite being in her own house. She also did not recognize her family and was speaking incomprehensibly. Her blood pressure (BP) is 150/80 mm Hg, heart rate (HR) is 90 beats per min- ute, temperature is 98.9°F, and her respiratory rate (RR) is 16 breaths per minute. On physical examination she is diaphoretic, agitated, and tremu- lous. Electrocardiogram (ECG) is sinus rhythm with normal ST segments and T waves. Which of the following is the most appropriate course of action for this patient?
- Administer a benzodiazepine to treat her ethanol withdrawal.
- Activate the stroke team and bring the patient directly to the computed tomo- graphic (CT) scanner.
- Get a stat fingerstick and administer dextrose if her blood sugar is low.
- Request a psychiatric consult for probable sundowning.
- Administer haloperidol for sedation.
2. A 74-year-old lethargic woman is brought to the ED by her Her daughter states that the patient has been progressively somnolent over the last week and could not be woken up today. The patient takes medications for diabetes, hypertension, hypothyroidism, and a recent ankle sprain, which is treated with a hydrocodone/acetaminophen combination. In the ED, the patient is profoundly lethargic, responsive only to pain, and has periorbital edema and delayed relaxation of the deep tendon reflexes. Her BP is 145/84 mm Hg, HR is 56 beats per minute, temperature is 94.8°F, and RR is 12 breaths per minute. Which of the following is the most likely diagnosis?
- Opioid overdose
- Myxedema coma
3. A 79-year-old man presents to the ED by paramedics with the chief complaint of agitation and confusion over the previous 12 He has a past medical history of schizophrenia and is not taking any of his antip- sychotics. His BP is 135/85 mm Hg, HR is 119 beats per minute, RR is 18 breaths per minute, oxygen saturation is 97% on room air, and fingerstick glucose is 135 mg/dL. Because of his agitation at triage, he was placed in wrist restraints. At this time, he is calm but confused. Examination reveals warm and clammy skin and 4-mm pupils that are equal and reactive. His cardiac examination reveals tachycardia and no murmurs. His lungs are clear to auscultation and his abdomen is soft and nontender. He is able to move all of his extremities. Which of the following is the most appropriate next step in management?
- Administer haloperidol or lorazepam.
- Consult psychiatry.
- Order a CT scan of his head.
- Send a urine toxicologic screen.
- Obtain a rectal temperature.
4. A 25-year-old man is brought to the ED by emergency medical ser- vice (EMS) accompanied by his girlfriend who reports that the patient had a seizure 30 minutes ago and is still The girlfriend reports that the patient is a known epileptic who has been doing well on his latest medi- cation regimen. The exact seizure medications are unknown. On arrival to the ED, the patient develops continuous clonic movements of his upper and lower extremities. The patient’s vital signs are BP of 162/85 mm Hg, HR of 110 beats per minute, and pulse oximetry of 91% on room air. Capil- lary glucose level is 95 mg/dL. Which of the following is the most appropri- ate next step in management?
- Place the patient in a lateral decubitus position.
- Administer lorazepam.
- Administer phenytoin.
- Perform rapid sequence intubation on the patient.
- Look up the patient’s medical records and administer his current antiepileptic regimen.
5. A 19-year-old college student presents to the ED complaining of headache, sore throat, myalgias, and rash that developed over the previous 12 Her BP is 95/60 mm Hg, HR is 132 beats per minute, temperature is 103.9°F, RR is 19 breaths per minute, and oxygen saturation is 98% on room air. She is confused and oriented only to person. Physical examina- tion is remarkable for pain with neck flexion, a petechial and purpuric rash on her extremities, and delayed capillary refill. Which of the following best describes the emergency physicians’ priority in managing this patient?
- Collect two sets of blood cultures prior to antibiotic administration.
- Call the patient’s parents and have them come immediately to the hospital.
- Call her roommate to gather more information.
- Begin fluid resuscitation, administer intravenous (IV) antibiotics, and perform a lumbar puncture (LP).
- Administer acetaminophen to see if her headache and fever resolve.
6. A 21-year-old college student is brought to the ED by her roommate who states that the patient has been very sleepy She has a history of diabetes and has not refilled her medication in over a week. Her BP is 95/61 mm Hg, HR is 132 beats per minute, temperature is 99.7°F, and RR is 20 breaths per minute. Her fingerstick glucose is 530 mg/dL. Which of the following choices most closely matches what you would expect to find on her arterial blood gas with electrolytes and urinalysis?
- pH 7.38, anion gap 5, normal urinalysis
- pH 7.57, anion gap 21, presence of glucose and leukocytes in urine
- pH 7.47, anion gap 12, presence of glucose and ketones in urine
- pH 7.26, anion gap 12, presence of glucose and ketones in urine
- pH 7.26, anion gap 21, presence of glucose and ketones in urine
7. A 65-year-old actively seizing woman is brought to the ED by She was found slumped over at the bus stop bench. EMS personnel state that when they found the woman, she was diaphoretic and her speech was garbled. En route to the hospital, she started to seize. As you wheel her to a room, the nurse gives you some of her vital signs that are a BP of 150/90 mm Hg, HR of 115 beats per minute, and oxygen saturation of 96%. Which of the following is the next best step in managing this patient?
- Request a rectal temperature to rule out meningitis.
- Call the CT technologist and tell them you are bringing over a seizing patient.
- Ask for a stat ECG and administer an aspirin.
- Check the patient’s fingerstick blood glucose level.
- Intubate the patient.
8. A 48-year-old man presents to the ED with ethanol His BP is 150/70 mm Hg, HR is 95 beats per minute, temperature is 97.9°F, RR is 14 breaths per minute, and oxygen saturation is 93% on room air. The patient is somnolent and snoring loudly with occasional gasps for air. On examination, the patient’s gag reflex is intact, his lungs are clear to ausculta- tion, heart is without murmurs, and abdomen is soft and nontender. He is rousable to stimulation. A head CT is negative for intracranial injury. His ethanol level is 270 mg/dL. Which of the following actions is most appro- priate to assist the patient with respirations?
- Nasal airway
- Oral airway
- Bag-valve-mask ventilation
- Laryngeal mask airway
- Tracheoesophageal airway
9. A 52-year-old woman is brought to the ED by her husband for altered mental status for 1 The patient has hypertension and diabetes but has not been taking her medications for the last 5 days since she lost her insur- ance and could not afford her prescriptions. Her BP is 168/91 mm Hg, HR is 125 beats per minute, temperature is 99.8°F, and RR is 18 breaths per minute. Her fingerstick glucose is 900 mg/dL. There is glucose in her urine but no ketones. Which of the following is the most appropriate next step in management?
- Administer IV fluids and insulin
- Obtain head CT scan
- Obtain ECG
- Obtain chest radiograph and urine culture
- Administer broad coverage antibiotics
10. A 45-year-old man is brought to the ED by his coworkers after collapsing to the floor while at A coworker states that the patient mistakenly took several tablets of his oral diabetic medications a few hours ago. The patient is unresponsive and diaphoretic. His BP is 142/78 mm Hg, HR is 115 beats per minute, temperature is 98.9°F, and RR is 12 breaths per minute. A bedside glucose reads 42 mg/dL. Which of the following is the most appropriate management of this patient?
- Administer IV dextrose, obtain repeat fingerstick glucose every hour, and, if normal after 6 hours, discharge the patient home.
- Administer IV dextrose and continue monitoring his blood sugar for at least 24 hours.
- Administer IV fluids and insulin.
- Administer IV fluids.
- Administer activated charcoal and IV fluids.
11. A 59-year-old man is brought into the ED accompanied by his son who states that his father is acting irritable and occasionally The son states that his father has a history of hepatitis from a transfusion he received many years ago. Over the past 5 years, his liver function slowly deteriorated. His vital signs include BP of 145/80 mm Hg, HR of 78 beats per minute, RR of 16 breaths per minute, oxygen saturation of 98%, and temperature of 98°F. Laboratory results are all within normal limits, except for an ammonia level that is significantly elevated. Which of the following is the best therapy?
- Vancomycin and gentamycin
- Lactulose and neomycin
- Ampicillin and gentamycin
12. A 40-year-old man who is an employee of the hospital is brought to the ED actively A coworker states that the patient has a known sei- zure disorder and currently takes phenytoin for the disorder. He also tells you that the patient has been under stress recently and may not have taken his last few doses of medication. You call for the nurse to place a face mask with 100% oxygen and gain IV access. You then ask for a medication to be drawn up. Which is the most appropriate initial medication you should administer in this actively seizing patient?
- Valproic acid
13. A 32-year-old gravida 1, para 1 who gave birth by normal vaginal delivery at 38 weeks’ gestation 2 days ago presents to the ED complain- ing of bilateral hand swelling and severe headache that started 2 hours ago. Her BP is 187/110 mm Hg, HR is 85 beats per minute, temperature is 5°F, and RR is 15 breaths per minute. Urinalysis reveals 3+ protein. When you are examining the patient, she proceeds to have a generalized tonic-clonic seizure. Which of the following is the most appropriate next step in management?
- Administer magnesium sulfate IV.
- Administer labetalol to reduce her BP and morphine sulfate to address her headache.
- Administer sumatriptan and place the patient into a dark quiet room.
- Administer a loading dose of phenytoin, order a head CT scan, and call for a neurology consult.
- Administer diazepam and normal saline IV.
14. An unconscious 51-year-old woman is brought to the ED by A friend states that the patient was complaining of feeling weak. She vom- ited and subsequently “blacked out” in the ambulance. The friend states that the patient has no medical problems and takes no medications. She also states that the patient smokes cigarettes and uses cocaine, and that they were snorting cocaine together prior to her blacking out. The patient’s BP is 195/80 mm Hg, HR is 50 beats per minute, temperature is 98.6°F, and RR is 7 breaths per minute. What is the eponym associated with her vital signs?
- Cushing syndrome
- Cushing reflex
- Cullen sign
- Charcot triad
- Chvostek sign
15. A 47-year-old man is brought to the ED by EMS after being persis- tently agitated at a business The patient’s coworkers state that he has been working nonstop for a day and a half and that he always seemed like a healthy guy who frequented bars every night. EMS administered 25 g of dextrose and thiamine with no symptom improvement. In the ED, the patient is anxious, confused, tremulous, and diaphoretic. He denies any medical problems, medications, or drug ingestions. His BP is 182/92 mm Hg, HR is 139 beats per minute, temperature is 100.4°F, RR is 18 breaths per minute, and fingerstick glucose is 103 mg/dL. An ECG reveals sinus tachycardia. Which of the following is the next best step?
- Administer acetaminophen.
- Administer folate.
- Administer diazepam.
- Recheck fingerstick glucose.
- Administer labetalol.
16. A 65-year-old man presents to the ED with a headache, drowsiness, and He has a history of long-standing hypertension. His BP is 230/120 mm Hg, pulse 87 beats per minute, RR 18 breaths per minutes, and oxygen saturation 97% on room air. On examination, you note papille- dema. A head CT scan is performed and there is no evidence of ischemia or hemorrhage. Which of the following is the most appropriate method to lower his BP?
- Administer propofol for rapid reduction in BP.
- Administer mannitol for rapid reduction in BP and intracranial pressure (ICP).
- Administer a high-dose diuretic to reduce preload.
- Administer labetalol until his BP is 140/80 mm Hg.
- Administer labetalol until his BP is 180/100 mm Hg.
17. A 74-year-old woman is brought to the ED by EMS for altered men- tal Her BP is 138/72 mm Hg, HR is 91 beats per minute, RR is 17 breaths per minute, and temperature is 100.9°F. A head CT is normal. LP results revealed the following:
White blood cell (WBC) count 1020/mL with 90% polymorphonuclear cells
Glucose 21 mg/dL
Protein 225 g/L
Which of the following is the most likely diagnosis?
- TB meningitis
- Bacterial meningitis
- Viral meningitis
- Fungal meningitis
18. A 67-year-old man presents to the ED for worsening His wife states that he received his first dose of chemotherapy for lung cancer 2 days ago. Over the last 24 hours, the patient became confused. His BP is 130/70 mm Hg, HR is 87 beats per minute, and temperature is 98.9°F. While in the ED, the patient seizes. You administer an antiepileptic and the seizure immediately stops. You compare his current electrolyte panel to one taken 2 days ago.
Which of the following is the most appropriate treatment?
- 0.45% saline
- 0.9% saline
- 3% saline
- 5% dextrose
- 50% dextrose
19. A 31-year-old woman with a history of schizophrenia presents to the ED for altered mental A friend states that the patient is on mul- tiple medications for her schizophrenia. Her BP is 150/80 mm Hg, HR 121 beats per minute, RR 20 breaths per minute, and temperature 104.5°F. On examination, the patient is diaphoretic with distinctive “lead-pipe” rigidity of her musculature. You believe the patient has neuroleptic malig- nant syndrome. After basic stabilizing measures, which of the following medications is most appropriate to administer?
20. A 56-year-old man is brought in from the homeless shelter for strange, irrational behavior, and unsteady gait for 1 A worker at the shelter reports that the patient is a frequent abuser of alcohol. On examination, the patient is alert but oriented to name only and is unable to give full history. He does not appear clinically intoxicated. You note horizontal nystagmus and ataxia. What is the most likely diagnosis?
- Wernicke encephalopathy
- Korsakoff syndrome
- Normal pressure hydrocephalus
- Central vertigo
- Alcohol withdrawal
21. An 18-year-old girl is brought to the ED from a party for agitation and attacking her boyfriend with a Her boyfriend admits that she had several liquor shots and used intranasal cocaine at the party prior to becoming agitated, paranoid, and attacking him. Her BP is 145/80 mm Hg, HR is 126 beats per minute, temperature is 100.8°F, and RR is 20 breaths per minute. The patient is agitated, screaming, and resisting examination. What is the next best step in the management of this patient?
- IV b-blocker
- IV benzodiazepine
- Drug abuse specialist consult
22. A 78-year-old woman is transferred from a nursing home with altered mental status and The nursing home reports that the patient was febrile to 102.3°F, disoriented, confused, and incontinent of urine. Her past medical history includes hypertension, a stroke with residual right-sided weakness, and nighttime agitation for which she was started on haloperidol 3 days ago. Her BP is 215/105 mm Hg, HR is 132 beats per minute, tem- perature is 102.8°F, and RR is 20 breaths per minute. On examination, the patient is oriented to name only, tremulous, diaphoretic, and has marked muscular rigidity and three out of five right upper- and lower-extremity strength. What is the most likely diagnosis?
- Urinary tract infection
- Malignant hyperthermia
- Neuroleptic malignant syndrome
- Recurrent stroke
23. A 54-year-old man is brought to the ED by his wife for bizarre The wife complains that her husband has not been acting like his usual self over the last several days. She states that he has not had any change in sleep, appetite, or activity level. She also recalls that her husband com- plained of morning headaches for the last 2 months. The patient is other- wise in good health and does not take any medications. His BP is 135/87 mm Hg, HR is 76 beats per minute, temperature is 98.9°F, and RR is 14 breaths per minute. His examination is otherwise unremarkable. Which of the following is the most likely diagnosis?
- Migraine headache
- Tension headache
- Subarachnoid hemorrhage
- Pseudotumor cerebri
- Frontal lobe mass
24. A 27-year-old woman is brought to the ED by her husband after hav- ing a first-time seizure at She has no past medical history and had no complications while delivering her newborn vaginally 1 week prior to pre- sentation. In the ED, her BP is 178/95 mm Hg, HR is 97 beats per minute, temperature is 99.1°F, and RR is 18 breaths per minute. On examination, she has mild edema of her hands and feet. The seizure stopped spontane- ously, but the patient is postictal appearing and cannot answer your ques- tions. Which of the following is the most appropriate diagnostic test?
- Complete blood count
- Head CT
25. A 46-year-old woman is brought to the ED by her husband for 1 day of worsening The patient has a history of systemic lupus erythematosus (SLE) and takes chronic oral steroids. She has not been feel- ing well for the last few days. Her BP is 167/92 mm Hg, HR is 95 beats per minute, temperature is 100.3°F, and RR is 16 breaths per minute. On examination, the patient is oriented to name and has diffuse petechiae on her torso and extremities. Laboratory results reveal hematocrit 23%, plate- lets 17,000/mL, BUN 38 mg/dL, and creatinine 1.9 mg/dL. Which of the following is the most likely diagnosis?
- Henoch-Schönlein purpura (HSP)
- Disseminated intravascular coagulopathy (DIC)
- von Willebrand disease
- Idiopathic thrombocytopenic purpura (ITP)
- Thrombotic thrombocytopenic purpura (TTP)
26. A 63-year-old man presents to the ED complaining of headache, vomiting, and “not being able to think straight” for 1 The patient states that he has hypertension and diabetes but ran out of his medications in the last week. His BP is 245/138 mm Hg, HR is 90 beats per minute, tem- perature is 98.7°F, and his RR is 14 breaths per minute. Fingerstick glucose is 178 mg/dL. On examination, the patient appears slightly confused and oriented to name and place only. The neurologic examination is significant for papilledema. Which of the following is the most appropriate next step in management?
- Nitroprusside IV
- Magnesium sulfate IV
- Metoprolol by mouth
- Hydrochlorothiazide by mouth
- Obtain head CT
27. A 26-year-old man with a long history of epilepsy is brought to the ED for a recent While in the ED, he is rhythmically moving his right leg and is unresponsive. Which of the following best describes this seizure pattern?
- Petit mal seizure
- Generalized tonic-clonic seizure
- Partial seizure with secondary generalization
- Simple partial seizure
- Complex partial seizure
28. A 58-year-old woman is brought into the ED after a witnessed syn- copal Upon arrival, the patient appears confused and agitated. Her vitals include HR of 89 beats per minute, BP of 145/70 mm Hg, RR of 16 breaths per minute, and oxygen saturation of 98% on room air. Within a few minutes, the patient is more alert and oriented. She denies any chest pain, headache, abdominal pain, or weakness preceding the event and is currently asymptomatic. She also states that she has not taken her antiepi- leptic medications in 2 days. The patient’s examination is unremarkable including a nonfocal neurologic examination. Given this patient’s history and evolving examination, what is the most likely etiology of this patient’s syncopal event?
- Cerebrovascular accident (CVA)
- Transient ischemic attack (TIA)
- Aortic dissection
- Pulmonary embolus