Neurology and Altered Mental Status
Approach altered mental status systematically: airway/breathing, glucose, then a structured search for toxic, metabolic, infectious, structural, and vascular causes. Distinguish delirium (acute, fluctuating, inattentive) from dementia (chronic, progressive) and from psychiatric causes. Know the workup for suspected stroke: time last known well, NIHSS, noncontrast CT to exclude hemorrhage, and eligibility for thrombolysis or thrombectomy. Understand seizure management, including status epilepticus (benzodiazepines first, then a second-line agent).
Traps
Questions test the traps of anchoring: attributing confusion to dementia or a UTI without excluding hypoglycemia, hypoxia, stroke, or drug toxicity. Do not give thrombolysis without excluding hemorrhage and checking contraindications. Recognize that a patient with a normal CT can still have an ischemic stroke, and that posterior circulation strokes can present with dizziness and subtle findings. Watch for the patient with alcohol use disorder and altered mentation - consider thiamine deficiency, hypoglycemia, and hepatic encephalopathy.
Rule of thumb
In any altered mental status, check glucose immediately. If focal deficits are present, treat as a stroke until proven otherwise and activate the stroke pathway.