Altered Mental Status in the Emergency Department

Austin T. Smith, MD; Jin H. Han, MD, MSc


Semin Neurol. 2019;39(1):5-19. 

In This Article

Physical Exam

In the initial assessment and management section under general approach to the patient with altered mental status, the initial physical exam should focus on the patient's airway, breathing, and circulation. This should be done in conjunction with a rapid but thorough neurologic exam and evaluation for hypoglycemia, stroke, sepsis, seizure activity, and opioid intoxication (Table 4). Once any vital signs, abnormalities, or immediate life-threatening causes have been addressed, a more thorough physical exam should be performed.

Head, Ears, Nose, and Throat

An examination of the head should be performed to look for any signs of trauma which may suggest an intracranial hemorrhage as the cause. The ears should be examined for signs of infection, hemotympanum, or Battle's sign, which can be a sign of a skull base fracture.[127] The nose and throat should also be examined for trauma or signs of infection.


A thorough examination of the eyes should be performed as they can be helpful for detecting several different disease processes. Ocular exam findings and the differential diagnosis are summarized on Table 7. The pupils should be examined for size and reactivity. Miosis or mydriasis may suggest opioid or anticholinergic toxicity, respectively. Extraocular movements should be tested even if the patient is seemingly unconscious, as this may be the only way a patient can communicate (such as in locked-in syndrome). Ophthalmoplegia may be present in patients with Wernicke's encephalopathy or increased intracranial pressure. Visual fields should be tested to evaluate for deficits which may suggest stroke. With the patient at rest, the eyes should also be examined for nystagmus which may suggest intoxication or stroke. The eyes should also be examined for the presence of exophthalmos or proptosis, which can be secondary to hyperparathyroidism, infection, or trauma. A funduscopic exam can also be performed to assess for papilledema, which may suggest increased intracranial pressure, or retinal subhyaloid hemorrhages, which may suggest subarachnoid hemorrhage.


The neck should be examined for masses, nodules, or thyromegaly, which may indicate thyroid dysfunction. The neck should also be evaluated for meningismus, suggestive of meningitis or subarachnoid hemorrhage, but the absence of such does not rule out either condition.[49]


The cardiac exam should evaluate for general perfusion, heart rate, heart rhythm, and any extra heart sounds. A new murmur may suggest endocarditis, which can result in bacteremia or septic emboli. It may also represent cardiac shock in a patient who is hypotensive and poorly perfused. A friction rub may suggest cardiac tamponade.


The pulmonary exam should evaluate for pulmonary edema, pneumonia, or pneumothorax. This can be done by auscultation with a stethoscope or with visualization using bedside ultrasound.


An abdominal exam should evaluate for tenderness, hepatomegaly, splenomegaly, and the presence of ascites. Tenderness or rigidity may suggest an acute abdomen from cholecystitis, appendicitis, diverticulitis, or volvulus, among other causes. Pain out of proportion to the physical exam may suggest mesenteric ischemia. Hepatosplenomegaly may suggest liver disease, a hematologic cause or an oncologic cause.


A thorough neurologic exam should assess for focal deficits in language strength, sensation, coordination, gait, and cranial nerve function. Orientation and other high-level cortical functions should be assessed as well. Deep tendon reflexes should be examined for hyperreflexia or hyporeflexia to evaluate for upper motor neuron lesions or infectious/demyelinating causes. The patient's gait should be examined if possible to assess for ataxia, antalgia, circumduction, or any other abnormalities. Gait disturbances, while often nonspecific, may suggest Wernicke's encephalopathy, toxicologic causes, or stroke. Tone, balance, coordination, and position sense should be assessed as well. Increased tone may suggest a hypermetabolic state such as serotonin syndrome, malignant hyperthermia, or neuromuscular malignant syndrome.


The genitourinary region should be inspected for any signs of infection. Males should be inspected for infection and females for infection and vaginal foreign bodies such as tampons. A rectal exam should be performed to evaluate for tone, blood, or pain out of proportion to exam. Decreased tone may suggest spinal cord injury from neoplasm, trauma, or infection. Pain may suggest prostatitis or an abscess. Blood or melena may suggest a gastrointestinal bleed.


A skin exam should evaluate for evidence of acute and chronic disease. Findings of chronic liver disease include jaundice, scleral icterus, and caput medusa, and may suggest hepatic encephalopathy. Dry or doughy skin may suggest hypothyroidism. Darkened or bronze skin may suggest Addison's disease.

Acute skin findings such as petechiae or purpura may suggest hematologic or infectious causes such as bacterial meningitis. The skin should also be assessed for soft-tissue infections, particularly in the decubitus regions which are more likely to be missed.

Additionally, the skin should be examined for any drug patches (e.g., fentanyl or scopolamine) or other potential chemical exposures which can result in AMS.