The differential diagnosis for altered mental status is extremely broad. Stuart Swadron MD and Mizuho Spangler DO discuss the most common causes of AMS and review a practical approach to initially assessing a patient with undifferentiated AMS.
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Altered Mental Status: Approach and DifferentialFull episode audio for MD edition43:35 min - 21 MB - M4AC3 - Altered Mental Status - Part 1 MP360 MB - MP3C3 - Altered Mental Status - Part 1 - Summary258 KB - PDF
David G., M.D. - February 2, 2016 6:32 PM
Wow, please drop the little skit that is supposed to bring us into the real-life situation. It sounded like an episode of the Powerpuff girls. "Timmy?" Really? And the humor of the "attending" physician was terrible--"get this man a cigar," and "let's get this woman's head some sieverts" (I paraphrase, as I can't bare to listen to it again.) Additionally her medicine was questionable. "Prepare to intubate" because the altered patient has no gag? First of all, a lot of awake normal people have no gag. Secondly, testing for a gag reflex in an altered patient could indeed cause a gag, which could cause vomiting, which could cause aspiration. Whether the patient is protecting her airway is a clinical call, not a simple bedside test.
Also, could you explain how syncope ends up on the mnemonic for altered MS?
Overall, good basic (though heavily opinion-based) discussion of the topic by Stuart and Mizhuho, but let's not dumb it down by the "real-life" theater.
Mel H. - February 3, 2016 7:14 AM
David thanks for the note. I wrote those scenes and of course they need work but we are trying something different. Can we create a little radio show and make it medically accurate and not lame? I reserve the right to completely fail. So I will keep experimenting for a while. Then get more user feedback and if the people hate the idea as you do, I will kill it. But I think there is something here if we can get the dialogue and tone right. It's Jimmy not Timmy he hates that! Given our current tech we might also be able to offer 2 versions of C3 - standard no BS, just Swad, Miz and emphasis and the ever evolving Radio Show version, users could easily choose which version they get. Mel
Tahsin K. - February 16, 2017 7:13 PM
I'd personally also prefer the standard version without the skits.
Charles W. - February 3, 2016 12:29 PM
I for one found the interaction between the attending and resident to be helpful, as well as funny. I'm not sure why Dr Glaser above was so irked by it. I actually thought the line about sieverts to the brain was hilarious! Anyways, just my two cents. Humour is an amazing way to promote retention. Keep up the good work!
Charles W. - February 3, 2016 12:30 PM
If I could just ask while I'm here commenting - can you compile all the C3 episodes onto a page that we can easily access? or allow us to download them individually on the app? I know they are individual units on the app now, but the old ones from episodes 120-ish are still within the whole episode so our little iphones get full too quickly trying to download them all. Thanks again.
Janelle V., PA-C - February 6, 2016 5:21 AM
Yes, please! I agree this would be helpful - I'm a new PA, and having easy access to all C3 episodes in one place would make it so much easier to review the basics.
Janelle V., PA-C - February 6, 2016 5:23 AM
Actually, I can't even find this episode on my iPhone app.
Dallas H. - February 3, 2016 7:45 PM
I quite enjoyed this segment! I love the C3 concept, thank you so much guys!
Joris T. - February 5, 2016 2:39 AM
The C3 concept is great, it was exactly the part that I missed in the standard EM-RAP podcast. Great for bringing it to us! Personally I quite enjoyed the show with its jokes and 'theater': It keeps me focused when the really important stuff is told :). So thanks and keep up the good work!
Mel H. - February 6, 2016 11:14 AM
I like the idea of curating the new (and old) C3's into a more easily found place. I will work with our tech team and maybe create a place called EMRAP.org/C3
Miguel A. - March 11, 2016 5:52 PM
This would be awesome!
William F., DO - February 8, 2016 8:35 PM
I love the C3. Can you guys stop pronouncing mnemonic as "pneumonic"? it"s as noticeable as reality show contestants who say "surreal" when they mean, "unreal". I've had to miss out on the most important and culturally relevant events in my lifetime because of that. Don't make me have to miss out on this, too. (The 2nd most important and culturally relevant event in my lifetime). Otherwise, love this. In fact, on second thought, me skipping reality shows for the whole "surreal" thing leaves this, now, as the most important thing, in my life. I have literally nothing else going on in my life, as much as that would probably surprise you.
Steve P - February 29, 2016 7:49 AM
Yes, thank you! EVERYONE wants to put a U in mnemonic! While I've noticed that people of higher intelligence tend to mispronounce and misspell more often, and recognize that my own attention to grammar is likely a sign of my inferior intellect, I can't stand it when doctors pronounce things incorrectly. The case can be made that it doesn't matter as long as you make the diagnosis and heal the patient. BUT I say if we're the only keepers of this medical lexicon, then we darn well better get it right or we should just scrap it all together. The singular of nares IS NOT NARE!!! (naris)
Lennard O. - February 9, 2016 2:33 AM
I love the concept of the C3. As a med student I can only say: This is the kind of lecture I always hoped to hear at my university, symptom/syndrome based learning is what medical education needs. Plus I really enjoy the somewhat goofy radio show style, but I'm a fan of the Mel Herbert/EmRap humour anyways.
Charles A. P.,M.D. - February 9, 2016 12:31 PM
This is great! I really enjoy all the C3 talks and the added interaction between resident and attending created a more engaging atmosphere. Thank you for creating this.
Jesse H. - February 13, 2016 1:30 PM
Innovative! Great way to bring life to the often dry material. I will stay tuned.
Chuck S. - February 15, 2016 8:32 PM
Was a little unnerved that you were teaching "check the gag reflex" for a couple of reasons: 1. really bad idea in someone with a potential belly full of beer and pizza as can make the airway very difficult and 2. there appears to be no good correlation between presence of absence of a gag reflex and airway protective reflexes. Swallowing of secretions is a much better measure.
Otherwise love these (and EMRAP
Marie-Claude C. - February 22, 2016 6:16 PM
Really good review ! Really funny, really helpful for a young family doctor like me. Hope to access all the C3's episodes. Thank you very much for your good work.
Isaac G. - March 1, 2016 2:15 PM
I really enjoyed this C3 episode. Please keep this format.
Bishan R., Dr - March 8, 2016 8:04 AM
I really enjoyed the C3 episode. Speaking as an resident in Australia studying for his boards - this format is both informative, entertaining and memorable (the latter being something that greatly augments my study). Using the format of the Attending and Intern is really good (I quite like the jokes - they are a bit larger than life, ZDogg style - but its more like a parody of reality - nice to have some theatre mixed up in there. Thanks - keep up the good work!
Laurie B. - March 15, 2016 3:01 PM
As a new ED NP, I love the C3 episodes. Actually, I find all of the EMRap material to be very valuable, especially Grand Rounds!
jkolb - March 31, 2016 12:47 PM
Being an old guy I find it interesting how old things that were thought to be resolved start showing up again. I generally avoid any comments on anything but in this C3 repeated mention of using the "gag" reflex as useful in the intubation decision made me cringe. The absence of presence of a gag reflex seems like a horrible way to decide need for intubation. Its presence or absence tells you very little about the ability to protect the airway and could on rare occasion induce vomiting followed by aspiration. Please see letter the editor Annals Emerg Med October 1995 Volume 26, issue 4 - No gag rule for intubation.
Tanel Lepik - April 10, 2016 6:49 AM
I wake up at 5am. My route to work takes about 2h30min. Things to keep me awake are coffee and this new format of C3. Funny, informative and entertaining. Please keep this format.
Aaron I. - April 20, 2016 9:31 AM
Love the C3 concept and format. The skits make it fun and keep things interesting.
Nazanin B. - April 20, 2016 11:10 PM
Great work. Thnx.
Is it possible to download the Summary for each episode as PDF format? Having a quick link or printable version really helps.
Mel H. - April 22, 2016 7:13 PM
Go to the downloads TAB and the PDF summaries are there...
Ian L. - October 22, 2016 5:15 PM
A lot to remember .Like a Dictionary of mnemonics and a Google Mneunics app .
E -Fast US Role re HIMAP as an additive .?
Ian L. - January 28, 2017 12:08 PM
Too much to remember for the time .
GO2 : Glucose Opiates Oxygen .
Asad T. - February 8, 2017 1:38 PM
I'm a big fan of the C3 setup. Excellent for me as a medical student transitioning into medicine. Thanks Dr. Mel and staff