Correct!
5. All of the above

The differential diagnosis for a change in mental status is large. A mnemonic that summarizes the differential and can be used to initiate evaluation AEIOU TIPS (Table 1) (1).

Table 1. Altered mental status mnemonic.

• A — Alcohol/Acidosis
• E — Endocrine/Epilepsy/Electrolytes/Encephalopathy
• I — Infection- meningitis, encephalitis, sepsis, septic shock; pneumonia, urinary tract infection, occult osteomyelitis.
• O— Opiates, Overdose
• U — Uremia/Underdose
• T — Trauma - head injury, blood loss (shock).
• I — Insulin
• P — Poisoning/Psychosis/pharmacology
• S — Stroke/Seizure/syncope

The patient has the potential for many of these. They would include infection with bacterial endocarditis given his loud murmur and fever; liver failure because of his history of prior liver disease and treatment with acetaminophen; and hypoglycemia although he has no particular reason from his history to develop hypoglycemia. Blood was drawn for initial laboratory evaluation and he was given 50 ml of 50% dextrose intravenously without response. Significant initial laboratory values are given in Table 2.

Table 2. Initial laboratory values.

• CBC: WBC 26.8 X 109 cells/L (normal 4.3-10.89 cells/L)
• BUN/creatinine: 93 mg/dL/2.7 mg/dL (normal 7-20 mg/dL/0.6 to 1.2 mg/dL)
• Aspartate Aminotransferase (AST): 1222 U/L (normal 10-40 U/L)                 
• Ammonia: 122 µmol/L (normal 11 to 32 µmol/L)
• Prothrombin time (PT): 20 seconds (normal 11 to 13.5 seconds)

What should be done next? (Click on the correct answer to be directed to the third of six pages)

1. Begin empiric antibiotics
2. CT of the head
3. Lactulose
4. 1 and 3
5. All of the above

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