by Dr. Ron Diamond

Hypoglycemia (low blood sugar): symptoms can include delirium or coma, palpitations, sweating, anxiety, tremor, vomiting. If in doubt, give candy or orange juice sweetened with sugar. In an emergency room, give 50 cc. of 50% dextrose for both treatment and diagnosis.

Diabetic Ketosis or non-ketotic hyperosmolarity (blood sugar so high that it upsets body chemistry): delirium with history of diabetes, increased breathing, sweet smell of acetone on breath (can be mistaken for smell of alcohol), dehydration, decreased blood pressure.

Wernickes-Korsakoff's syndrome: acute thiamine (vitamin B6) deficiency so severe that it can cause rapid brain damage. Usually found in alcoholics. Symptoms include nystagmus (rapid small jerking movements of eyes), cerebellar ataxia (person moves as if drunk), evidence of peripheral neuropathy, ocular palsies (inability to move both eyes together in all directions) If in any doubt, give thiamine l00 mg. IM. This is not diagnostic but will prevent any further brain damage.

DT's (delirium tremens): drug withdrawal from alcohol or other sedative hypnotics. Frequently missed and can be medically very serious. Symptoms include elevated autonomic signs, agitation, visual and tactile hallucinations and history of alcohol abuse. Onset is usually three to four days after reduction or discontinuation of alcohol.

Hypoxia (low blood oxygen): from pneumonia, heart attack, COPD (chronic obstructive pulmonary disease), arrythmias (abnormal heart rhythm), etc.

Meningitis (infection of the covering of the brain): be alert for stiff neck and fever.

Subarachnoid hemorrhage (rapid arterial bleeding into the brain): stiff neck, fluctuating consciousness and headache. If there is a fluctuating consciousness along with stiff neck and headache, a spinal tap for diagnosis needs to be done immediately. Subdural hematoma (bleeding from veins under the outside covering of the brain, which compresses the brain over hours to weeks or even longer): symptoms are variable but frequently (not invariably) there is a history of head trauma.

Anticholinergic (atropine) poisoning: from overdose of tricyclics or over-the-counter drugs, or from organophosphate insecticides. Classic symptoms include: Flushing "red as a beet" x Mouth dry "dry as a bone" Dilated pupils "blind as a bat" Delirious "mad as a hatter" These patients will also have increased pulse and sometimes elevated blood pressure. Most fatalities are from cardiac arrythmias, although seizures are not uncommon.

Progressive neurological diseases Multiple sclerosis: no typical signs or symptoms. It may begin very suddenly and affect any part of the neurological system. Early in its course, diagnosis may be extremely difficult.

Huntington's chorea: hereditary illness that includes movement disorder but can present with psychosis initially. Alzheimer's disease and Pick's disease: progressive diseases that cause dementia, but can initially present in a wide variety of ways. Alzheimer causes diffuse dementia, while Pick's primarily affects the frontal lobes of the brain.

Central nervous system infections Encephalitis (viral infection of the brain-usually Herpes Simplex): usually presents with fever and seizures, but various mental symptoms including catatonia or psychosis may present before any clear cut neurological symptoms. Usually has a fluctuating mental status. Neurosyphilis (syphilis of the central nervous system). HIV infections: HIV encepalopathy commonly includes apathy, decreased spontaneity and depression and may present before any other signs of AIDs are present. AIDS can also first present as delirium with paranoia and other prominant psychotic features.

Space occupying lesions within the skull Brain tumors, Bleeding within skull, Brain abcesses

Metabolic disorders

Accumulation of toxins from severe liver or kidney disease. Disturbances in electrolytes, either too low a serum level of sodium or too high a serum level of calcium. Acute intermittent porphyria (disease of porphyrin metabolism): very rare, but may present as classical psychosis. Often Endocrine disorders Myxedema (underactive thyroid gland-hypothyroidism) Cushing's syndrome (too much cortisol caused by overactive adrenal gland or overactive pituitary gland) Hypoglycemia, either from insulin secreting tumor or administration of insulin

Deficiency states Thiamine deficiency: Wernicke-Korsakoff amnestic syndrome; Pellegra (nicotinic acid defeciency) and other B complex deficiencies; Zinc deficiency Temporal lobe epilepsy (or partial complex seizure disorder) Drugs-licit and illicit