At this today’s morning report we talked through a case of acute, agitated encephalopathy in a gentleman who had recently been diagnosed with atrial fibrillation. While thorough history and examination ruled out many of the usual suspects (i.e. intoxication, infection, etc.) we were reminded of the extensive list of causes of altered mental status (see the table pulled from UpToDate below).
When the available lab data identified an anion gap acidosis, the team was quick to discover an elevated serum lactate level, and eventually found the patient to be in an acute shock state. Further evaluation identified pulmonary hypertension and cor pulmonale.