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INTRODUCTION

APPROACH TO THE PATIENT Disorders of Consciousness

Disorders of consciousness are common; these always signify a disorder of the nervous system. Assessment should determine whether there is a change in level of consciousness (drowsy, stuporous, comatose) and/or content of consciousness (confusion, perseveration, hallucinations). Confusion is a lack of clarity in thinking with inattentiveness; delirium is used to describe an acute confusional state; stupor, a state in which vigorous stimuli are needed to elicit a response; coma, a condition of unresponsiveness. Pts in such states are usually seriously ill, and etiologic factors must be assessed (Tables 17-1 and 17-2).

TABLE 17-1COMMON ETIOLOGIES OF DELIRIUM

DELIRIUM

Delirium is a clinical diagnosis made at the bedside; a careful history and physical exam are necessary, focusing on common etiologies of delirium, especially toxins and metabolic conditions. Observation will usually reveal an altered level of consciousness or a deficit of attention. Attention can be assessed through a simple bedside test of digits forward—pts are asked to repeat successively longer random strings of digits beginning with two digits in a row; a digit span of four digits or less usually indicates an attentional deficit unless hearing or language barriers are present. Delirium is vastly underrecognized, especially in pts presenting with a quiet, hypoactive state.

A cost-effective approach to the evaluation of delirium allows the history and physical exam to guide tests. No single algorithm will fit all pts due to the large number of potential etiologies, but one step-wise approach is shown in Table 17-2.

TABLE 17-2STEPWISE EVALUATION OF A PATIENT WITH DELIRIUM

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