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Behavioral Health Issues — Differential Diagnosis — Clinical Pathway: Emergency

Behavioral Health Issues Clinical Pathway — Emergency Department

Review Differential Diagnosis for Altered Mental Status and Psychosis

Causes of Altered Mental Status

AEIOU-TIPS

A Alcohol
E Endocrine, encephalopathy, electrolytes
I Insulin (hypoglycemia)
O Oxygen (hypoxia), opiates (drugs of abuse)
U Uremia
T Toxicants, trauma, temperature
I Infection
P Psychiatric, porphyria
S Stroke, shock, subarachnoid hemorrhage
Space-occupying CNS lesion

VITAMINS

V Vascular — stroke, atypical migraine
I Infection — CNS, sepsis
T Trauma — hemorrhage, concussion
A A lot of toxicants
M Metabolic — hyperammonemia, thyrotoxicosis, hypo/hyperglycemia, heat stroke, uremia
I Intussusception
N Neoplasm
S Seizure, post-ictal

Psychosis

Disruption in thinking, accompanied by delusions or hallucinations

Organic Drug Toxicity Non-organic
  • Substrate deficiency
    • e.g., hypoglycemia, hypoxia
  • CNS abnormality
  • Systemic lupus erythematosus
  • Metabolic disease
    • e.g., urea cycle defect, acute intermittent porphyria, Wilson disease
  • Thyrotoxicosis
  • Serotonin syndrome
  • Neuroleptic malignant syndrome
  • Drug withdrawal
  • Acute psychosis
  • Acute paranoid schizophrenia
  • Bipolar disorder
  • Emotional rage

Further Diagnostic Testing

Screening for Organic Disease

Studies Lab
Blood
  • CMP, CBC
  • ESR, CRP if concerns for inflammatory disease
  • TFTs
  • Ammonia
  • RPR, if clinically indicated
  • Ceruloplasmin
Urine
  • UA
  • HCG
Toxicology
  • CHOP Urine, serum
Hormonal
  • Adrenal level, prolactin
Imaging
  • ECG
    • Exposure history
    • Baseline if antipsychotic or antidepressant drug use anticipated
  • Brain imaging
    • Abnormal neurologic exam
CSF Lumbar puncture, if concern for encephalopathy/encephalitis

 

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