Altered Mental Status

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Altered mental status is possibly the most common presenting complaint for patients in the emergency room, especially gomers. Delirium, confusion, agitated, sleepy, lethargic, doesn't matter... It all falls under the umbrella term of altered mental status.


Nearly 100% of patients over than the age of 65 have experienced altered mental status in any of its glorious forms. In fact, the risk of altered mental status increases with age, length of stay, number of comorbidities, number of medications, and number of alien bodies introduced (central line, arterial line, Foley catheter, etc.).


Ha! What doesn't cause altered mental status? What we will say is that in the 1940s, electroencephalograms (EEGs) helped document that altered mental status was the result of global cortical dysfunction. What it did not capture was seizures, because EEGs never capture seizures. In sum, when you have a patient with altered mental status, just document "multifactorial" as the cause and you'll be all set.

As for the health care professional population, the most common causes of altered mental status are hanger pains, uremia from not urinating all month, and cirrhosis from too many liver rounds.[1][2][3]

Symptoms and Signs

You name it: disturbance in attention, fluctuating attention, memory deficit, disorientation, agitation, confusion, throwing poop, ripping out PICCs and Foleys, and making known to all their impressive vocabulary of curse words.[4][5] Sundowning is a subtype of altered mental status where gomers and gomeres go batsh*t crazy the second the sun sets.


  1. History - History is never useful. Ignore.
  2. Physical exam - Exam also never useful. Ignore.
  3. Neurologic exam - Same as physical exam.[6]
  4. Labs - Now we're talking: complete blood count, chemistries (chloride is crucial here, more so than creatinine or liver function tests), troponin (come on, you've ordered troponins for less), blood glucose, TSH, RPR, B12... You know what? F**k it, add a rectal swab.

Differential Diagnosis

Wowsah, the differential for this one is a doozy! Because it is so long, we have decided in the interest of time to omit it entirely.


Despite the hundreds of etiologies for altered mental status that we failed to list above, the treatment is always the same:

  1. Empiric antibiotics with vancomycin and Zosyn
  2. 11-to-1 sitter
  3. Heavy-duty restraints
  4. Haldol Blowdart
  5. Ativan Diffuser
  6. Palliative Care consult


  1. 2016 ACLS Hangry Algorithm (Gomerblog)
  2. Forgot-to-Pee Syndrome Afflicting Millions of Health Care Workers (Gomerblog)
  3. After Counseling Patient on Evils of Alcohol Abuse, Medical Team Leaves Work & Gets Absolutely Hammered (Gomerblog)
  4. Patient Can’t Wait to Yank Out Foley, Cause Bloodbath (Gomerblog)
  5. Sweet Little Old Lady Has Impressive Vocabulary of Profanity (Gomerblog)
  6. No Neurology Consult: MICU Intern Startles All (Gomerblog)

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