HPI
presenting with altered mental status, characterized as decreased responsiveness that was discovered today by a family member. Currently, the symptoms are persistent. The last known well time is unknown.
No recent head trauma, illicit drug use, medication changes.

There is associated generalized weakness with difficulty standing and walking.
The patient’s usual cognition is alert and oriented.
The patient’s usual ability to walk is walking without assistance.

Associated symptoms include:
Negative recent illness or fever
Negative nausea or vomiting
Negative headache
Negative focal numbness or weakness
Negative seizure activity

Social History: Patient denies any recent alcohol

ROS: Negative for fever. Negative for black or bloody stools. A 10 point ROS was done and was negative except as otherwise indicated above.

Physical Exam:
General: Decreased level of alertness but arousable to voice. Mild distress.
HEENT: pupils are equal and reactive to light, EOM intact, gag reflex intact, mucous membranes moist

Neuro:
patient is responsive to voice,
speech is normal
cranial nerves two through 10 are intact
cerebellar function is normal is tested
motor and sensory function are grossly intact in all 4 extremities

Neck: supple, normal inspection; no thyromegaly.
Cardiovascular: Regular rate and rhythm; no rubs, murmur, gallops.
Respiratory: clear to auscultation bilaterally, normal respiratory effort, no wheezes, no JVD
Abdominal: soft, no tenderness, normal abdominal bowel sounds.
Skin: warm, well perfused, no rashes, normal capillary refill, no icterus.
Psych: no apparent psychosis
Extremities: no injuries, no pedal edema

MDM Discharge

The patient suffered an episode of altered mental status, but the cause appears to be ___, and there is no concern for a dangerous emergency cause such as, but not limited to, CNS infection, severe Toxidrome, severe metabolic derangement, or stroke.

At the time of discharge, the patient is back to baseline mental status.

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MDM Admit

The patient is suffering from significant altered mental status. Possible causes considered included, but were not limited to, CNS or other infection, severe Toxidrome, severe metabolic derangement, stroke, or intracranial hemorrhage.

Based on the history, exam, and test results, the cause of the altered mental status seems to be [_]. Based on the severity of the patient’s condition, hospitalization is required for further testing and treatment.