What is the admission note dot phrase for a patient presenting with altered mental status?

From the Guidelines

The admission note for a patient presenting with altered mental status should include a comprehensive assessment of the patient's condition, focusing on potential causes and initial management, as outlined in the most recent guidelines 1. When evaluating a patient with altered mental status, it is essential to consider the broad range of potential causes, including metabolic, infectious, toxicologic, neurologic, and psychiatric factors.

• The assessment should begin with a chief complaint of altered mental status, followed by a detailed history including onset, progression, and associated symptoms.
• Vital signs, general appearance, and a thorough neurological examination, including Glasgow Coma Scale score, pupillary response, motor function, and reflexes, should be documented.
• Mental status examination findings, such as orientation, attention, and memory, should also be included.
• Relevant laboratory results, including complete blood count, comprehensive metabolic panel, urinalysis, toxicology screen, blood cultures if infection is suspected, and arterial blood gas if respiratory issues are present, should be documented.
• Imaging results, such as head CT or MRI, should be included if performed.
• Differential diagnoses should consider metabolic causes (electrolyte abnormalities, hypoglycemia, uremia), infectious causes (meningitis, encephalitis, sepsis), toxicologic causes (medication effects, substance use), neurologic causes (stroke, seizure, intracranial hemorrhage), and psychiatric causes.
• The initial management plan should include airway protection if needed, fluid resuscitation, correction of metabolic abnormalities, empiric antibiotics if infection is suspected, and any specific treatments for identified causes.
• Disposition plans, monitoring requirements, and consultation requests to neurology or psychiatry should be included as appropriate, as delirium, a common cause of altered mental status, is considered a medical emergency and requires early detection and accurate diagnosis to prevent increased mortality 1. The economic impact of delirium in the United States is profound, with total costs estimated at $38 to $152 billion each year, highlighting the importance of prompt and effective management 1.
• A structured approach to the evaluation and management of altered mental status is crucial, as it represents a symptom rather than a diagnosis and requires thorough investigation to identify and address the underlying cause.
• Validated assessment scales, such as the Richmond Agitation Sedation Scale and Glasgow Coma Scale, may be employed to objectively quantify the severity of symptoms 1.
• The cause of altered mental status in patients across all age groups remains undiagnosed in slightly greater than 5% of cases, and overall mortality in patients with altered mental status is approximately 8.1%, which is significantly higher in elderly patients 1.

From the Research

Admission Note Dot Phrase for Altered Mental Status

The admission note dot phrase for a patient presenting with altered mental status is not explicitly stated in the provided studies. However, the following information can be used to construct a dot phrase:

• The patient presents with altered mental status, which is a broad spectrum of disease processes that can be caused by primary neurologic insults or systemic illnesses resulting in end-organ dysfunction of the brain 2.
• The differential diagnosis for altered mental status is broad and includes primary CNS disorders, intoxication, organ system dysfunction, and endocrine/metabolic diseases 3.
• A structured approach to assessing patients with altered mental status can help identify specific causal etiologies and rule out worst-case scenarios 4, 5.
• The assessment should include a focused history and physical examination, as well as laboratory and radiographic testing to identify potential causes of altered mental status 2, 3, 5.

Key Components of the Dot Phrase

• Presentation: Altered mental status
• Differential diagnosis: Broad range of disease processes, including primary CNS disorders, intoxication, organ system dysfunction, and endocrine/metabolic diseases
• Assessment: Focused history and physical examination, laboratory and radiographic testing
• Potential causes: Primary neurologic insults, systemic illnesses, toxicologic, neurologic, and infectious causes

Example Dot Phrase

• "Altered mental status, differential diagnosis includes primary CNS disorders, intoxication, organ system dysfunction, and endocrine/metabolic diseases, plan to conduct focused history and physical examination, laboratory and radiographic testing to identify potential causes" 2, 3, 4, 5