Definition of mental status changes
An alteration in mental status refers to general changes in brain function, such as confusion, memory loss, change in alertness, loss of orientation to self, time and place, strange behavior, disruptions in perception and psychomotor skills.
Terms used to refer to conditions hallmarked by mental status changes
Confusion, lethargy, dementia, encephalopathy and organic brain syndrome
Mini Mental State Exam
Orientation to time- 5 Orientation to place- 5 Registration (repeated named prompts)- 3 Attention and Calculation (serial 7s, spelling "world" backwards)- 5 Recall (from registration words)- 3 Language (name a pencil and a watch)- 2 Repetition (speaking back a phrase)- 1 Complex commands (draw the figure shown)- 6 TOTAL= 30
- Any score equal or over 24- normal
- 19-23 is mild impairment
- 10-18 is moderate impairment
- less than 9 is severe impairment
Best initial step to evaluate a patient presenting with global neurologic dysfunction?
CMP- comprehensive metabolic panel
-Metabolic causes (i.e., hyper/hyponatremia, hyper/hypoglycemia, hypercalcemia, hyper/hypothyroidism, hypoxia/hypercapnea, hepatic encephalopathy, uremic encephalopathy, drug intoxication/withdrawal, Wernicke encephalopathy)
Other causes of global neurologic dysfunction
- seizures-postictal state
- hypertensive encephalopathy
-As opposed to stroke, structural lesions, arrythmias which lead to focal, asymmetric neurologic changes rather than global, symmetric changes
Possible cause of global neuro dysfunction is hypercalcemia, treatment for this is
- First step in the management of hypercalcemia is fluid resuscitation with intravenous isotonic saline.
- Calcitonin, peptide hormone, decreases bone resorption and increases renal calcium excretion. Can rapidly reduce total calcium within 4-6 hours and lose their benefit after 48 hours. So works quickly but does not sustain response well.
- Bisphosphonates block osteoclast-mediated bone resorption, thus inhibiting calcium release. Acts 2-4 days after administration and results are longer lasting. IV preparations are preferred over oral formulations.
- Glucocorticoids can be used to treat hypercalcemia by decreasing gastrointestinal absorption of calcium.
What is the best initial test to evaluate the cause of the patient’s hypercalcemia?
Parathyroid hormone measurement (PTH)
A recent increase in calcium with weight loss points towards
a malignant neoplasm
Long-term, stable mild hypercalcemia without symptoms or weight loss is suggestive of
Most common cause of hypercalcemia with low PTH level is
- Osteolytic process such as in Multiple myeloma.
- PTHrP secretion such as from squamous cell lung cancer.
- Tumors producing 1,25 dihyroxyVitamin D such as in lymphoma.
- Others: 25-OH vitamin D intoxication, granulomatous disorders, hyperthyroidism, immobilization and adrenal insufficiency.