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of the autonomic nervous system and of generalized or focal cerebral disease At times, a left hemispheral lesion causing a mild Wernicke aphasia resembles a confusional state in that the stream of thought, as judged by verbal output, is incoherent The prominence of paraphasias and neologisms in spontaneous speech, dif culties in auditory comprehension, and normal nonverbal behavior mark the disorder as aphasic in nature The distinction between an acute confusional state and dementia may be dif cult at times, particularly if the mode of onset and the course of the mental decline are not known The patient with an acute confusional state is said to have a clouded sensorium (a somewhat ambiguous term referring to a symptom complex of inattention, disorientation, perhaps drowsiness, and an inclination to inaccurate perceptions and sometimes to hallucinations and delusions), whereas the patient with dementia usually has a clear sensorium.

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In the demented patient, there are usually a number of frontal release signs such as grasping, groping, sucking, and paratonic rigidity of the limbs However, some demented patients are as beclouded and bewildered as those with confusional psychosis, and the two conditions are distinguishable only by differences in their mode of onset and clinical course This suggests that the affected parts of the nervous system may be the same in both conditions As indicated earlier, schizophrenia and manicdepressive psychosis can usually be separated from the confusional states by the presence of a clear sensorium and relatively intact memory function Once a case has been appropriately classi ed, it is important to determine its clinical associations (Table 20-1) A thorough medical and neurologic examination, computed tomography or magnetic resonance imaging, and in cases with fever or with no other apparent cause lumbar puncture should be performed.

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The medical, neurologic, and laboratory ndings (including measurements of Na, Ca, CO2, BUN, NH3, calcium, glucose, PAO2, PCO2, toxic screen, etc) determine the underlying disease and its treatment, and they also give information concerning prognosis An approach to the laboratory tests that are useful in revealing the common conditions that give rise to the confusional state when the cause is not self-evident from the history and physical examination is given in Table 20-2; but as always, the choice of tests is governed by the Table 20-2 An initial approach to the laboratory evaluation of the acutely confused patient I Afebrile, no meningismus, and no focal neurologic signs A Endogenous metabolic disorders: glucose, sodium, calcium, BUN, PAO2, PCO2, NH3, T4, and special tests in particular circumstances (for porphyria, Hashimoto thyroid disease, etc) B Exogenous toxic state: toxicologic screening of blood and urine II.

include hydrogen consumption that may be 20 to 100 percent higher than that for fixed bed resid desulfurization process, and loss of liquid and hydrogen to high gas yields The distillate products require further hydrotreating and conversion to produce transportation fuels Thus, the options for refiners processing heavy high sulfur will be a combination of upgrading schemes and by-product utilization Other heavy oil upgrading options include: (a) deep cut vacuum distillation, (b) solvent deasphalting prior to conversion, and (c) hydrogenation prior to conversion For the present, using a schematic refinery operation (Fig 31), new processes for the conversion of residua and heavy oils will probably be used in concert with visbreaking with some degree of hydroprocessing as a primary conversion step Other processes may replace or augment the deasphalting units in many refineries.

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