• Medications (opioids, benzos, anticholinergics, tricyclics, H2 blockers, etc..)
• Metabolic (hypoglycemia, hypo/hypernatremia, uremia, hypoxia, hypercapnea, hypothyroidism)
• Toxins (alcohol, others)
• Infection (bacteremia, meningitis)
• CNS (subdural hematoma, CVA)

• What is the baseline mental status? If disorientation is longstanding, this might be dementia.
• Is there a history of an underlying systemic illness?
• What medications is he/she receiving?
• Is there a history of trauma? Especially relevant for patients on anticoagulation.
• Is the patient an alcoholic and now withdrawing?

• What is the nature and extent of the acute confusional state?

Vitals

• Bradycardia and hypertension suggestive of increased ICP? (Cushings triad).
• Fever, tachycardia suggestive of infection?
• Hypothermia suggestive of sepsis or hypothyroidism?
• Respiratory rate (slow=opioids)

HEENT

• Evidence of head trauma?
• Pupils- pinpoint? (opioids); fixed, dilated?
• Neck- resistant to passive flexion? (subarachnoid bleed, meningitis)

Pulmonary

• Any suggestion of hypoxia, CO2 retention?

Neuro

• Any focal deficit suggestive of an intracranial process?

• Mental status examination

• Glasgow Coma Scale

• Review chart, medication list, labs.
• Consider the following studies: fingerstick glucose, chem-7, ABG (if hypoxia suspected).
• Consider head CT in the presence of focal neurologic finding, headache, history of trauma or anticoagulation.
• Consider lumbar puncture in febrile patient without other explanation.
• If patient received an opioid, consider Narcan 0.4mg-2mg iv.
• If patient is out of control, consider Haldol 0.5-2 mg or Ativan 0.5-2mg iv, im, or po.