{"id":7504,"date":"2025-09-01T00:01:00","date_gmt":"2025-09-01T08:01:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=7504"},"modified":"2025-10-01T11:38:26","modified_gmt":"2025-10-01T19:38:26","slug":"usmle-step-2-ck-question-of-the-day-altered-mental-status","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-altered-mental-status","title":{"rendered":"USMLE\u00ae Step 2 CK Question of the Day:\u00a0Altered mental status"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-altered-mental-status\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_Question_is%E2%80%A6\" >The correct answer to today\u2019s USMLE\u00ae Step 2 Question is\u2026<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-altered-mental-status\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-altered-mental-status\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-altered-mental-status\/#Major_Takeaway\" >Major Takeaway&nbsp;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-altered-mental-status\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-altered-mental-status\/#References\" >References&nbsp;<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Today, we\u2019re examining a clinical case of a 65-year-old man in the ER with an altered mental state. What are the next steps to identify the likely cause?<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 65-year-old man presents to the emergency department with confusion and lethargy over the past week. The patient has been increasingly fatigued and has lost a significant amount of weight over the past two months. Over the past several days, he has also experienced nausea, vomiting, increased thirst, and frequent urination. Additionally, he has had a persistent cough for the past three months. He has a 40-pack-year smoking history and has not seen a physician in several years. Temperature is 37.0 \u00b0C (98.6 \u00b0F), pulse is 90\/min, respiratory rate is 18\/min, blood pressure is 148\/80 mmHg, and oxygen saturation is 94% on room air. On physical examination, the patient is disoriented to time and place and has dry mucous membranes. There are no focal neurological deficits, but generalized weakness is present. A cardiovascular exam is unremarkable. Diffuse Rhonchi are heard over the left lung field. Laboratory results are shown below. <\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td><strong>Serum Chemistry<\/strong>\u00a0<\/td><td><strong>Results<\/strong>&nbsp;<\/td><\/tr><tr><td><strong>Sodium<\/strong>&nbsp;<\/td><td>140 mEq\/L&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/td><\/tr><tr><td><strong>Potassium<\/strong>&nbsp;<\/td><td>3.8 mEq\/L&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/td><\/tr><tr><td><strong>Chloride<\/strong>&nbsp;<\/td><td>98 mEq\/L&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/td><\/tr><tr><td><strong>Creatinine<\/strong>&nbsp;<\/td><td>1.2 mg\/dL&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/td><\/tr><tr><td><strong>Calcium<\/strong>&nbsp;<\/td><td>13.6 mg\/dL&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/td><\/tr><tr><td><strong>Glucose<\/strong>&nbsp;<\/td><td>100 mg\/dL&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/td><\/tr><tr><td><strong>Albumin<\/strong>&nbsp;<\/td><td>3.4 g\/dL&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/td><\/tr><tr><td><strong>Phosphorous<\/strong>&nbsp;<\/td><td>2.9 mg\/dL&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following is the best next step in determining the cause of this patient\u2019s altered mental status?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Magnetic resonance imaging (MRI) of the brain<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Abdominal ultrasound<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Serum protein electrophoresis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Chest radiograph<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Lumbar puncture<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Osmosis.org at the University College London, UK\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/DIp3u0oTLo4?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_Question_is%E2%80%A6\"><\/span>The correct answer to today\u2019s USMLE\u00ae Step 2 Question is\u2026<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Chest radiograph<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct:<\/strong> See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Magnetic resonance imaging (MRI) of the brain<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> While MRI of the brain can detect central nervous system causes of altered mental status and may be used for staging if cancer is diagnosed, the presence of hypercalcemia along with his smoking history and lung findings makes lung malignancy more likely.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Abdominal ultrasound<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> An abdominal ultrasound is unlikely to identify the primary cause of altered mental status and hypercalcemia in this patient who most likely has lung cancer.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Serum protein electrophoresis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Serum protein electrophoresis is used to diagnose multiple myeloma and can be part of the workup for hypercalcemia. This patient&#8217;s history and presentation are more suggestive of hypercalcemia due to lung cancer; therefore, a chest radiograph should be performed next to confirm the diagnosis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Lumbar puncture<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> A lumbar puncture is typically performed to diagnose neurologic infections or central nervous system pathologies. It will not help diagnose the underlying cause of this patient\u2019s altered mental status, hypercalcemia, and lung findings.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents with altered mental status (AMS) likely due to hypercalcemia. The recent symptoms of nausea, vomiting, increased thirst, and frequent urination are consistent with hypercalcemia. Given the significant weight loss, chronic cough, heavy smoking history, and lung exam findings, hypercalcemia is most likely due to an underlying malignancy, such as lung cancer in this patient. A chest radiograph is the most appropriate next step to evaluate lung mass, which could be the cause of hypercalcemia and altered mental status.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Determining the etiology of AMS requires targeted diagnostic tests based on clinical suspicion. For metabolic causes, such as hyperglycemia or uremia, basic blood tests like a basic metabolic panel are essential. Infectious causes (e.g., meningitis) may require a lumbar puncture to analyze cerebrospinal fluid, while imaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) scans of the brain are necessary to identify structural causes such as stroke or tumors. Specific imaging, like a chest radiograph or abdominal ultrasound, may be needed to identify underlying malignancies or other systemic causes of AMS. Toxicologic screening should be performed when drug overdose or poisoning is suspected.\u00a0<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">In patients presenting with altered mental status, identifying the underlying cause often requires targeted diagnostic tests, such as serum laboratory studies to assess for metabolic imbalances, imaging studies for structural abnormalities or underlying malignances or toxicological screening for suspected poisoning or overdoses.\u00a0\u00a0<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch the Osmosis video:<\/strong> <a href=\"https:\/\/www.osmosis.org\/learn\/Approach_to_altered_mental_status:_Clinical_sciences\">Approach to altered mental status: Clinical Sciences<\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>LaHue SC, Douglas VC. Approach to Altered Mental Status and Inpatient Delirium. Neurol Clin. 2022;40(1):45-57. doi: 10.1016\/j.ncl.2021.08.004<\/li>\n\n\n\n<li>Selvadurai C. Altered Mental Statu. In: Leppert BC, ed. Netter\u2019s Integrated Review of Medicine. Elsevier, Inc.; 2021:53-58.<\/li>\n\n\n\n<li>Veauthier B, Hornecker JR, Thrasher T. Recent-Onset Altered Mental Status: Evaluation and Management. Am Fam Physician. 2021;104(5):461-470.<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><a href=\"https:\/\/www.osmosis.org\/plans\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/06\/Blog_Display_Ads_MD1_2023.png\" alt=\"\" class=\"wp-image-4438\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/06\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/06\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more USMLE\u00ae Step 2 CK practice questions? Try Osmosis from Elsevier today! Access your\u00a0<em><a href=\"http:\/\/osmosis.org\/create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a><\/em>\u00a0and discover why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A 65-year-old man with confusion and weight loss presents to the ER. What is the best next step to identify the cause of his altered mental status?<\/p>\n","protected":false},"author":202,"featured_media":7506,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,16,1366,1370,45],"tags":[1416,1414,733,1418,440,1415,1417,1419,220,952],"class_list":["post-7504","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-do","category-questions","category-step-2-questions","category-step-2","tag-altered-mental-status","tag-chest-x-ray","tag-clinical-case","tag-diagnostic-imaging","tag-emergency-medicine","tag-hypercalcemia","tag-lung-cancer","tag-metabolic-disorders","tag-patient-evaluation","tag-usmle-step-2-ck"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 CK Question of the Day:\u00a0Altered mental status - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-altered-mental-status\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 CK Question of the Day:\u00a0Altered mental status - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"A 65-year-old man with confusion and weight loss presents to the ER. 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