AMS Without Active Cancer
REMEMBER: AMS with brain stem abnormalities is a basilar artery occlusion until proven otherwise. You will need a stat CTH and CTA brain/neck.
Establish premorbid status
Where and with whom does the patient currently live?
What is their baseline cognitive and functional status?
Prior workup completed
Prior Brain Imaging
Prior EEG
Prior LP
Bedside cognitive testing (MOCA, SAGE, MMSE)
Establish the timeline
Symptoms started prior to hospitalization
Symptoms started during hospitalization
Symptoms are episodic
Differential Diagnosis
Septic Encephalopathy
Current sepsis or systemic infection
Toxic Encephalitis
Drug/alcohol withdrawal, Wernickes
Serotonin syndrome (recent serotonergic med changes)
NMS (recent dopamine blocker changes)
Med side-effects: recent steroids, benzos, anticholinergics, opiates, etc.
Cefepime-related neurotoxicity: recent cefepime use with new or worsening renal function
Hepatically metabolized meds (benzos, barbiturates, etc.) in a patient with new/worsening liver dysfunction
Stroke
Recent surgery (peri-operative stroke)
New or chronic afib
Periods of severe HTN
Periods of hypotension (watershed infarcts)
ICH, PRES
Periods of severe HTN
Hypoxic Brain Injury
Periods of hypoxia or hypercarbia
Metabolic Encephalopathy
New or worsening hepatic or renal impairment
Severe hyponatremia, hypercalcemia, hypomagnesemia, hypo/hyperglycemia
Dietary restrictions, gastric bypass, eating disorder, alcoholism, hyperemesis, poor PO intake, or chronically ill (deficiencies of B1/B12, copper, folate, vitamin E)
History of thyroid disease
Paraneoplastic Encephalopathy
Subacute symptoms
Infectious
Sexually active, history of STI (HIV, neurosyphilis)
Sleep Apnea
Choking/gasping for air during sleep
Daytime sleepiness
Dementia
Chronic slowly progressive
AMS-Specific Review of Systems
Headache (CNS infection, PRES, vasculitis)
Abnormal movements, seizure-like activity, convulsions
Episodes of altered awareness
Diplopia
Dysarthria
Dysphagia
Numbness/Tingling
Weakness
Incoordination
Lightheadedness
Vertigo
Falls/Change in gait
Need for ambulation device
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