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BACKGROUND

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Altered mental status (AMS) is a broadly applied term used to describe any change in a patient’s baseline behavior, cognitive abilities, or awareness of and interaction with the environment. The presentation of altered mental status in a pediatric patient encompasses a wide variety of manifestations, ranging from confusion to coma, and is associated with a myriad of etiologies. The workup requires careful assessment of not only the patient’s presentation and examination, but also a detailed history of prodromal symptoms, potential exposures (both environmental and pharmacologic), and preceding trauma. The evaluation is frequently complicated by the fact that the patient is unable to participate in providing information due to either impaired mental state or developmental age, and clinicians must often rely on parents or caregivers to elicit contextual details to assist in the assessment. In particular, it is important to understand the patient’s baseline mental status and appreciate how the current presentation differs.

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PATIENT HISTORY

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Initial evaluation should be targeted at stabilizing the patient by following the standard assessment and management of the patient’s airway, breathing, circulation, disabilities, and exposures. This is followed by a careful history from the patient (whenever possible) and/or parent(s) or caregivers, and should focus on the following elements:

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  1. Baseline behavior and neurologic state: This is particularly important given the developmental variations in norms among different pediatric age groups, and the variations observed among children with developmental and intellectual disabilities.

  2. Onset and course of symptoms: Obtain information on the acuity, timing, and course of the symptoms. The impairments may be described as persistent, intermittent, acute, recurrent, progressive, or fluctuating.

  3. Associated symptoms: Obtain a history of any concurrent or preceding symptoms including a history of fever, headache, seizures, hallucinations, nausea, vomiting, diarrhea, incontinence, changes in urinary frequency or oral intake.

  4. Trauma: Obtain a careful history of preceding trauma or observed injuries, such as bruising, especially if no clear mechanism of injury exists.

  5. Past medical history: Obtain a thorough account of existing medical and psychiatric conditions (chronic or acute) or recent procedures.

  6. Medications: Obtain a detailed delineation of any prescription medication changes, including new medications, recent dose changes, or recent discontinuation of medications. Also collect a list of medications belonging to other household members to which the patient may have had access.

  7. Social history: Obtain a history of access to or risk of recreational drug and alcohol use. Collect information on potential family members or household contacts using recreational drugs. Assess potential stressors in the home or at school.

  8. Travel history/exposures: Obtain an account of recent travel within the United States and internationally. Assess outdoor activities and potential exposures to tick bites or mosquito bites. Obtain a history of environmental exposure, such as access to lead paint or household cleaning items. Assess for any other close contacts with similar symptoms.

  9. Family history: Obtain a family history focusing on autoimmune disease, migraines, bleeding disorders, seizure disorders, and psychiatric illness.

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