CC = acute confusion

HPI

• 37 yo male acute onset of confusion and slurred speech 15 min prior to arrival
• Was in his normal state of health prior to this, and had no complaints to co-workers during the work-day

Pmhx:

• Insulin dependent diabetes

Social

• Nonsmoker, occasional ETOH, no known drug use

VS

T 97.7 oral

HR 65

BP 96/60

O2 sat 96% on RA

Exam

General: eyes closed, intermittently following commands, moving all extremities

HEENT: Pupils 3 mm and reactive. oropharynx clear

Cardio: no MRG

Pulm: lungs clear

Abd: soft, nontender

Neuro: GCS is Eye opening: 4, Verbal: 4 (confused speech) Motor: 6  = 14

Bedside diagnostics

• Fingerstick glucose: 101
• ECG: sinus rhythm, no ST/T wave changes, normal intervals

CT brain

• Slightly degraded by motion artifact, no acute abnormalities

Ddx

Think VINDICATE

• V = Vascular (ruptured AVM, SAH)
• I = Iatrogenic (medications or street drugs)
• N = Neoplasm (brain)
• D = Degerative
• I = Infectious (meningitis/encephalitis)
• C = Congential
• A = Autoimmune
• T = Trauma (occult head trauma)
• E = Endocrine, metabolic (hypoglycemia, hyperthyroid, hyponatremia, hypercalcemia)

Family arrives

• Pt recently had his insulin regimen changed, and has had several episodes of hypoglycemia within the past week, often resulting in prolonged episodes of altered mental status

Case resolution

• Repeat glucose at bedside = 58
• 25g of dextrose administered
• Pt immediately wakes up and returns to normal mental status, with no complaints
• He is discharged home shortly afterwards after adjustment to sliding scale insulin

Teaching points

• This patient's initial glucose was 101
• Point of care glucose may not be accurate, or should be repeated in patients with suspected hypoglycemia
• The clinical manifestations of hypoglycemia are variable in symptoms and severity
• Hypoglcyemia is the #1 cause of acute change in mental status 
• Consider empiric IV dextrose in any acute change in mental status in patients known or suspected to be taking insulin, regardless of point of care glucose readings