08 September 2009


I haven't looked at the numbers lately, but Altered Mental Status, or AMS, must be in the top ten, if not the top five most common ER presentations.  AMS, as a triage complaint, is like a bizarre little birthday present for an ER doc.  You just don't know what you're going to get when you walk into the room -- and there's a tremendous range of possibilities.  It could be someone with a stroke, or a septic septuagenarian.  Odds are, it's just a drunk, or someone stoned on street drugs, or overdosed on prescription meds.  Less exciting and much more work (and infinitely more likely to be a huge pain in the butt).  They may have nothing at all, or something really trivial like a fainting spell.  Sometimes you get the really interesting stuff presenting with AMS: a first time DKA or a carbon monoxide poisoning, for example, which is a fun detective game requiring good clinical skills.  I've seen it all, a million times over, so I'm quite comfortable with the protocol, but you never really know what it is till you get in there.

This was a little old fellow who had been found down by his family this morning.  He had been in great health and living alone more or less independently despite being almost ninety.  His daughter had spoken with him the night before and he had seemed fine, though they had been concerned about a progressively worsening unsteady gait.  He was found in his bathroom (they went to check on him when he did not answer the phone in the morning) and his bed had not been slept in, so it was safe to presume he'd been on the floor all night.  He had a goodly sized contusion on his cheek and forehead, already purpling up nicely, implying that he had gone to ground pretty hard.   He was awake but cold (about 34 degrees body temp), having been on the floor all night, but his vitals were otherwise normal.  His mental status was not terrible, but he was definitely groggy and slurring his speech a bit, and his neuro exam (limited due to his mental status) was nonfocal.

So, by simple probability alone, I constructed the following preliminary differential, looking for a common cause for both the fall and the AMS:
  • UTI causing weakness and instability
  • Some other infection causing weakness and instability
  • Bathroom-associated syncope (common in the elderly)
  • A simple mechanical fall (too weak/shook up/head injured to get up)
  • Stroke (less likely given the exam, but always possible)
  • Floor-dweller's disease (hypothermia, rhabdomyolysis, dehydration, renal failure, etc; unlikely given the short down time)
  • Medication effect (gotta get the list)
  • Dementia with family denial (also common)
  • "The Other Stuff"
And we went ahead and triggered the standard work-up.  Truth be told, I was busy chatting and the exceptional nursing staff had already ordered the complete work-up before I even got in to see the patient (yes, I am a redundant feature of our ED).  Shortly thereafter, he was lined & labbed, cleansed and foleyed and off to CT scan while I got to know the family a bit.  Unlike the standard neglectful/overanxious families, they were really nice, reasonable, well-grounded folks -- an absolute pleasure to talk to.  That should have been a red flag for me.

The "Code Blue" call from CT scan was my next wake-up call.  Truth be told, it wasn't a code per se, but the excitable CT tech called one anyway when the patient began to seize as he came off the table.  (Fair enough.)  A bit of ativan ended the seizure and the team whisked him back to the ED while I skimmed through the images.  This caught my attention right quick:


If you don't look at CT scans often, let me help you out a bit:


Vasogenic Edema is swelling in the brain induced by increased pressure or inflammatory conditions.  It can be seen from the late effects of a stroke, from severe hypertension, or from a brain tumor.  I knew this wasn't stroke-related because of the acute onset and the relatively normal neuro exam.  Hypertensive encephalopathy is more global, not localized (and his blood pressure was OK). And, though CT isn't great at showing mass lesions, that whitish thing sure looked like a tumor.  When I got back to the ER, a quick biopsy of the records showed that he had been treated a couple of years ago for Stage Ib adenocarcinoma of the lung, now thought to be in remission.  This cancer does commonly metastasize to the brain.  Damn.

So the story (or at least my portion of it) ends there.  I got to tell this nice family that "Pop's" cancer was back and that it was probably going to kill him.  We did the usual acute interventions and he went upstairs.  And I moved on to the next patient, who happened to be a drunk and here for altered mental status.

And that's AMS for you in a nutshell.  You never know what you're going to get.

And, just for the record, cancer sucks.


  1. Sorry, I'm just an interested consumer...not a med pro.

    >>they were really nice, reasonable, well-grounded folks -- an absolute pleasure to talk to. That should have been a red flag for me.

    What in that should have been a red flag for you?

  2. Canuck Med Student9/08/2009 4:47 PM

    It means the patient has almost universally something horrible. It's only the cranky, upset, pissed off families who have grannies and grampy's with lumps and bumps.

    Great story doc.

  3. I like the nod to Forrest Gump, too.

  4. The Canadian is right (which is the first time I have ever said that in any context). The red flag is that bad things happen to nice people, and when I meet some nice people in the ER my hair stands up on end because I can sense something very bad about to come their way, in contrast to the drug seekers and dirt bags who are (apparently) almost impossible to kill.

    J -- very good on the Gump. I thought of that too, but didn't want to go there overtly.

  5. It isn't that bad things happen to nice responsible people, but that nice responsible don't come in trying to blame every little complaint on someone else and demand that you fix it yesterday (and give them some Vicodin or Oxycontin while you are at it).

    Goodness and responsibility do not increase morbidity, but they decrease the chances you will be in the ED for something that is insignificant. Jerks are there so often for minor stuff, that it is a surprise when they actually have something significant.

    (yes, I am a redundant feature of our ED).

    We know. Aren't you getting carried away with the redundancy, by writing this? ;-)


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