Template for Patient Presenting with Altered Mental Status
The initial management of a patient with altered mental status should focus on immediate assessment of vital signs, glucose levels, and oxygenation while simultaneously considering life-threatening reversible causes. 1, 2
Initial Assessment (Primary Survey)
Patient presents with altered mental status characterized by [specific description of mental status changes]. Vital signs are: Temperature ___, Heart Rate ___, Blood Pressure ___, Respiratory Rate ___, Oxygen Saturation ___%.
The patient [does/does not] have a history of [psychiatric illness, substance use, neurological conditions, metabolic disorders]. [Include any relevant past medical history]
On examination, the patient is [level of consciousness: alert, confused, lethargic, obtunded, or comatose]. [Include description of pupillary response, focal neurological deficits if present, and any signs of trauma].
Immediate Interventions
- Airway: [Patent/Requires intervention]
- Breathing: [Adequate/Supplemental oxygen initiated at ___ L/min]
- Circulation: [IV access established with ___ gauge catheter]
- Blood glucose measured: ___ mg/dL [If <70 mg/dL, administered IV glucose] 3
- Naloxone ___ mg [IV/IM/SC] administered [if opioid overdose suspected] 4
Diagnostic Workup
Laboratory studies obtained:
- Complete blood count: ___
- Basic metabolic panel: ___
- Liver function tests: ___
- Urinalysis: ___
- Blood cultures: [if febrile]
- Thyroid function tests: ___
- Toxicology screen: ___
Imaging:
- Head CT [performed/ordered] to evaluate for [stroke, hemorrhage, mass, etc.] 1
- [Additional imaging as indicated]
Assessment of Potential Etiologies
The differential diagnosis includes:
- Neurological: [stroke, seizure, CNS infection] 1, 5
- Infectious: [UTI, pneumonia, sepsis, meningitis] 3, 1
- Metabolic: [hypoglycemia, electrolyte abnormalities] 1
- Toxicological: [medication effect, substance intoxication or withdrawal] 1, 6
- Psychiatric: [if relevant after medical causes excluded] 3
Treatment Plan
Based on the initial assessment and diagnostic findings, the following interventions were initiated:
- [Specific treatments based on suspected etiology]
- [Supportive care measures]
- [Disposition plan: admission, observation, discharge with follow-up]
The patient will be monitored for [specific parameters] and reassessed in [timeframe] for response to interventions.
Additional Considerations
Family members report that [relevant history from collateral sources]. The patient [has/does not have] advance directives regarding [relevant medical decisions].
[Include any special considerations based on age, comorbidities, or specific circumstances]
Bold text indicates the most critical recommendation for initial management of altered mental status.