When There Are Acute Changes In Mental Status In Patients With Diabetes
As podiatric physicians in 2010, we are better trained than ever to manage patients’ problems. Even more importantly, we are well versed in making appropriate, well-timed referrals when needed. In the following case study, that particular acumen was critically important.
A 78-year-old male with type 2 diabetes underwent resection of the first metatarsophalangeal base and debridement of an underlying ulcer, which has at times been infected. The plan was to inspect the bone for osteomyelitis, place the patient on oral antibiotics and not primarily close the plantar lesion, but pack it open instead. Resection of the phalangeal base would ease the deforming hallux interphalangeus.
Examination revealed a hallux limitus and the physician determined that at the patient’s age and activity level, a Keller arthroplasty would serve him well, preventing further breakdown and possible osteomyelitis. The plantar lesion did not undergo primary closure but physicians packed it instead.
The hospital discharged the patient within a week after bone cultures and histology showed no evidence of osteomyelitis. He received a prescription for oral antibiotics and received instruction to keep a clinic appointment in 48 hours. However, he was a no-show for his appointment. Phone calls to his home, all of which were documented, went unanswered over a period of two weeks.
About a month after his discharge from the hospital, the patient went to the emergency department of the hospital accompanied by his wife. His extremity was in the same dressing he received upon preparation for discharge although now it was soiled and loose. His wife reported that they had never filled the prescription for antibiotics because they “did not understand the instructions about the medicine or coming back.” She also noted that they “didn’t have anything to change the dressings with.”
When the patient went to the emergency department, he was running a fever and “not making any sense,” according to his wife. When pressed for an explanation, she told the residents and attendings that when her husband woke up, he was not able to complete a sentence and he barely recognized her. She asked if he wanted a cup of coffee and he looked at her as if she had asked him if he wanted a cup of dirt instead. This frightened her. She got him his usual cup of coffee and put it up to his lips to prompt him in his usual activity. He acted like he did not know how to open his lips.
This patient’s past medical history is positive for type 2 diabetes, which was diagnosed at the age of 34. The man is hypertensive, moderately obese and has early signs of renal disease. The patient neither smokes nor drinks. He has a history of diabetic foot ulcerations having had two on the right hallux interphalangeal joint.
What To Consider In The Differential Diagnosis
Patients who have an acute change in mental status commonly present to the emergency department and this presents a difficult diagnostic task. It is important to conduct a focused history and physical exam. As a surgeon, it is your responsibility to take charge in the management of your patient. The more you can figure out upon the initial evaluation, the more time you will save (instead of just automatically handing your patient off to another service such as infectious disease, neurology or internal medicine).
A common mnemonic to consider is AEIOU-TIPSM, which is as follows:1
A: alcohol, toxins
E: endocrine, electrolytes
I: insulin, diabetes-related, hypoglycemia
O: oxygen, opiates
T: trauma, temperature
P: psychiatric, poisoning, porphyria
S: stroke, seizure, shock, subarachnoid hemorrhage
M: metabolic; hyperammonia