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Diseases » Delirium » Tests
 

Diagnostic Tests for Delirium

Contents
  1. Delirium: Introduction
  2. Symptoms of Delirium
  3. Diagnosis
  4. Home Diagnostic Testing
  5. Failure to Diagnose
  6. Alternative Diagnoses
  7. Misdiagnosis

Delirium Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Delirium:

Delirium Diagnosis: Book Excerpts

Diagnosis of Delirium: medical news summaries:

The following medical news items are relevant to diagnosis of Delirium:

Diagnostic Tests for Delirium: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Delirium.

DEMENTIA: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine laboratory tests include a CBC, sedimentation rate, chemistry panel, VDRL test, HIV antibody titer, ANA, blood alcohol level, urine drug screens, thyroid profile, serum B 12 , and folic acid. A CT scan should probably be done in all cases. An EEG may be helpful in demonstrating drug intoxication. A spinal tap may need to be done to diagnose central nervous system lues. The best test for that is the fluorescent treponema antibody absorption test (FTA-ABS). MRI may be useful in distinguishing Alzheimer's disease from cerebral arteriosclerosis, as in cerebral arteriosclerosis small infarcts may be demonstrated. A radioiodinated serum albumin (RISA) cisternography study is useful to diagnose normal pressure hydrocephalus. Arterial blood gases should be drawn. Psychiatric testing will help differentiate organic brain syndrome from other psychiatric disorders and malingering. A neurologist or psychiatrist should be consulted before ordering expensive diagnostic tests.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

HALLUCINATIONS: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

A blood alcohol level and urine drug screen are essential at the outset. Most physicians will want to refer the patient to a psychiatrist if these studies are negative. However, the interested physician may proceed further with a wake-and-sleep EEG to identify psychomotor epilepsy, or a CT scan and MRI to identify brain tumors and other causes of organic brain syndrome. Remember, the MRI costs twice as much as a CT scan. A spinal tap will be helpful in diagnosing central nervous system lues. A sleep study will help diagnose narcolepsy. Psychometric testing will help identify schizophrenia and other psychiatric disorders.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

SYNCOPE: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

The diagnostic workup includes a CBC, sedimentation rate, urinalysis, chemistry panel, VDRL test, thyroid profile, glucose tolerance test, EKG, and chest x-ray. Several blood pressure recordings in the recumbent and upright positions should be made. If hypoglycemia is suspected, a 72-hr fast and a tolbutamide tolerance test should be done. The drug history should always be reviewed. A toxicology screen may be helpful.

Most cases will require 24-hr Holter monitoring or event Holter monitoring. In addition, other cardiovascular studies, such as echocardiography and His' bundle studies, may need to be done. Exercise tolerance testing is useful when the syncope seems to be exercise induced. An upright-tilt test is helpful when vasodepressor syncope is suspected, especially when combined with isoproterenol infusion. Signal-averaged EKG can be useful if a ventricular arrhythmia is suspected. If transient ischemic attacks are suspected, a carotid scan and cerebral angiography may be necessary. If the syncopal attacks are thought to be due to epilepsy, a wake-and-sleep EEG may need to be done. A CT scan or MRI of the brain may need to be done.

A cardiologist or neurologist should be consulted before ordering expensive diagnostic tests. A psychiatrist may also need to be consulted.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

DELIRIUM: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine laboratory tests include a CBC, sedimentation rate, ANA, chemistry panel including electrolytes and BUN and VDRL tests, a blood alcohol level, urinalysis, and urine drug screen. A CT scan of the brain and EEG is usually indicated also. Acute delirium may be an indication to administer intravenous glucose and thiamine. If there is fever, blood cultures and a spinal tap for analysis and culture need to be done. Arterial blood gases and carboxyhemoglobin should be determined. Generally, a neurologist or neurosurgeon should be consulted early.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Agitation: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Determine the severity of the patient’s agitation by examining the number and quality of agitation-induced behaviors, such as emotional lability, confusion, memory loss, hyperactivity, and hostility. Obtain a history from the patient or a family member, including diet, known allergies, and use of herbal medicine.

Ask if the patient is being treated for any illnesses. Has he had any recent infections, trauma, stress, or changes in sleep patterns? Ask the patient about prescribed or over-the-counter drug use, including supplements and herbal medicines. Check for signs of drug abuse, such as needle tracks and dilated pupils. Ask about alcohol intake. Obtain the patient’s baseline vital signs and neurologic status for future comparison.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Confusion: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When you take his history, ask the patient to describe what's bothering him. He may not report confusion as his chief complaint, but may suffer from memory loss, persistent apprehension, or the inability to concentrate. He may be unable to respond logically to direct questions. Check with a family member or friend about its onset and frequency. Find out, too, if the patient has a history of head trauma or a cardiopulmonary, metabolic, cerebrovascular, or neurologic disorder. Which medications is he taking, if any? Ask about any changes in eating or sleeping habits and in drug or alcohol use.

Perform an assessment to determine the presence of systemic disorders. Check the patient's vital signs, and assess him for changes in blood pressure, temperature, and pulse.

Next, perform a neurologic assessment to establish the patient's level of consciousness.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Level of consciousness, decreased: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Try to obtain history information from the patient, if he’s lucid, and from his family. Did the patient complain of a headache, dizziness, nausea, vision or hearing disturbances, weakness, fatigue, or other problems before his LOC decreased? Has his family noticed changes in the patient’s behavior, personality, memory, or temperament? Also ask about a history of neurologic disease, cancer, or recent trauma or infections; drug and alcohol use; and the development of other signs and symptoms.

Because a decreased LOC can result from a disorder affecting virtually any body system, tailor the remainder of your evaluation according to the patient’s associated symptoms.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Syncope: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient reports a fainting episode, gather information about the episode from him and his family. Did he feel weak, light-headed, nauseous, or sweaty just before he fainted? Did he get up quickly from a chair or from lying down? During the fainting episode, did he have muscle spasms or incontinence? How long was he unconscious? When he regained consciousness, was he alert or confused? Did he have a headache? Has he fainted before? If so, how often does it occur?

Next, take the patient’s vital signs and examine him for any injuries that may have occurred during his fall.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Agitation: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Determine the severity of the patient’s agitation by examining the number and quality of agitation-induced behaviors, such as emotional lability, confusion, memory loss, hyperactivity, and hostility. Obtain a history from the patient or a family member, including diet, known allergies, and use of prescribed or over-the-counter drugs, including supplements and herbal medicines.

Ask if the patient is being treated for any illnesses. Has he had any recent infections, trauma, stress, or changes in sleep patterns? Check for signs of drug abuse, such as needle tracks and dilated pupils, and ask about alcohol intake. Obtain baseline vital signs and neurologic status for future comparison.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Confusion: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When you take his history, ask the patient to describe what’s bothering him. He may not report confusion as his chief complaint but may complain of memory loss, persistent apprehension, or the inability to concentrate. He may be unable to respond logically to direct questions. Check with a family member or friend about the onset and frequency of the patient’s confusion. Find out, too, if the patient has a history of head trauma or a cardiopulmonary, metabolic, cerebrovascular, or neurologic disorder. Which medications is he taking, if any? Ask about any changes in eating or sleeping habits and in drug or alcohol use.

Perform an assessment to determine the presence of systemic disorders. Check vital signs, and assess the patient for changes in blood pressure, temperature, and pulse.

Next, perform a neurologic assessment to establish the patient’s level of consciousness.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Level of consciousness, decreased: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Try to obtain history information from the patient, if he’s lucid, and from his family. Did the patient complain of headache, dizziness, nausea, visual or hearing disturbances, weakness, fatigue, or any other problems before his LOC decreased? Has his family noticed any changes in the patient’s behavior, personality, memory, or temperament? Also ask about a history of neurologic disease, cancer, or recent trauma or infections; drug and alcohol use; and the development of other signs and symptoms.

Because decreased LOC can result from a disorder affecting virtually any body system, tailor the remainder of your evaluation according to the patient’s associated symptoms.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Seizures, complex partial: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you witness a complex partial seizure, never attempt to restrain the patient. Instead, lead him gently to a safe area. (Exception: Don’t approach him if he’s angry or violent.) Calmly encourage him to sit down, and remain with him until he’s fully alert. After the seizure, ask him if he experienced an aura. Record all observations and findings.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Syncope: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient reports a fainting episode, gather information about the episode from him and his family. Did he feel weak, light-headed, nauseous, or sweaty just before he fainted? Did he get up quickly from a chair or from lying down? During the fainting episode, did he have muscle spasms or incontinence? How long was he unconscious? When he regained consciousness, was he alert or confused? Did he have a headache? Has he fainted before? If so, how often does it occur?

Next, take the patient’s vital signs and examine him for any injuries that may have occurred during his fall.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Confusion: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Focused physical examination. This should include vital signs, psychomotor characteristics, assessment of skin, hair, and nail beds; and
a funduscopic examination. A screening neurologic examination should include a check for nuchal rigidity, and an assessment of Kernig’s and Brudzinski’s signs. Positive findings warrant further testing. The Folstein Mini-Mental State examination (2) can help assess cognitive functioning (Chapter 4.5). The Confusion Assessment Method may be used to help detect delirium (3).

Testing

 A. Clinical laboratory tests. These should include a complete blood count with differential, urinalysis, toxicology screen, serum chemistry panel, and appropriate medication levels. Vitamin B12 and folate levels, serologic test for syphilis, and thyroid function studies can be drawn. As clinically indicated, blood gases can also be checked. Based on history and examination, additional studies may include cerebrospinal fluid examination, heavy metals screen, and erythrocyte sedimentation rate (and others, as needed for vasculitis). An electroencephalogram (EEG) can be particularly useful in distinguishing delirium from psychiatric presentations—in delirium, the EEG will show diffuse slowing, except in cases of sedative drugs and withdrawal when low amplitude fast activity is seen; the EEG is normal in psychiatric syndromes.

 B. Diagnostic imaging. Magnetic resonance imaging is indicated for first psychotic breaks, new onset of confusion after age 50 years, and in the presence of focal neurologic findings.

Diagnostic assessment

. Assume organic causes until proved otherwise. Delirium is more likely in those populations noted above, and is typically characterized by disorientation, a fluctuating symptom course, and alterations in the sleep–wake cycle. Paranoia may be seen. Be alert to the presence of visual hallucinations, which can suggest the possibility of delirium. A dementia history is typically one of long intellectual decline with usual levels of alertness and attention. Orientation is often impaired, as are recent and remote memory. Perceptual disturbances are often absent, unlike delirium (4). Acute psychoses caused by schizophrenia are often characterized by hallucinations, delusions, and formal thought disorder and do not typically include disorientation or altered levels of consciousness. Symptoms tend not to fluctuate and memory is intact. Psychoses that develop as part of major depression or mania follow the onset of affective symptoms. Conversion disorders can involve hallucinations in the absence of other psychotic symptoms. La belle indifference may be present, but no symptom fluctuation or sleep–wake alteration is seen. Dissociative states can include loss of memory, including personal data, and perhaps disorientation, but these are not embedded in other changes. Episodes are usually short and perceptual disturbances are rare. Anxiety-like symptoms may precede dissociation. Acute and posttraumatic symptoms follow traumatic events. Acute stress disorder, by definition, remits within 4 weeks, but has symptoms similar to posttraumatic stress disorder. Orientation is intact, concentration can be impaired, and increased vigilance may be present. Patients may seem detached or in a daze. Nightmares and flashbacks often occur but no perceptual disturbances or thought disorganization is seen. Memory is intact, except perhaps for the traumatic event. Signs of autonomic arousal may be seen, especially with recall of the event. EEG changes are absent in psychiatric disorders.


References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.

2. Folstein MF, Folstein SE, McHugh PR. The Folstein Mini-Mental State Examination: a practical method for grading the cognitive state of patients for the clinician. J Psychiatric Res 1975;12:189–198.

3. Inouye SK, vanDyck CH. Clarifying confusion: the confusion assessment method. Ann Intern Med 1990;113:941–946.

4. Lipowski ZJ. Delirium (acute confusional states). JAMA 1987;258:1789–1792.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Dementia: Physical examination.
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

The patient should undergo a thorough general and neurologic examination and Mini-Mental Status Examination (MMSE). Look for focal neurologic deficits and assess cognitive function (memory, language, perception, praxis, attention, judgment, calculation and visuospatial function). Other neuropsychiatric testing is available.

Testing

 A. Clinical laboratory tests. The major value in laboratory tests is to look for potentially treatable causes of dementia. Basic tests should include complete blood count, electrolytes, basic chemistry (glucose, calcium, lipid panel), liver and thyroid function tests, vitamin B12, folate, urinalysis, erythrocyte sedimentation rate, and serologic test for syphilis. In addition, if the history indicates, consider human immunodeficieny virus (HIV) testing as well as heavy metals and toxic screens.

 B. Diagnostic imaging. Computerized tomography is usually sufficient to rule out surgical (subdural hematoma, normal pressure hydrocephalus, tumor) and most cerebrovascular causes of dementia. Although more expensive, magnetic resonance imaging is superior to visualize small lacunae and temporal lobe atrophy (2). Positive emission tomography scanning is very expensive and seems to have greater resolution and sensitivity, but for now seems to be more of a research tool.

C. Other testing. Electroencephalography generally shows nonspecific changes except in cases of seizures, CJD, and hepatic encephalopathy. The MMSE, which is a widely used, simple tool that requires less than 10 minutes to perform, enables assessment of cognitive function (Chapter 4.5). Expected results somewhat depend on the patient’s educational level.

Diagnostic assessment.

The differential diagnosis in dementia most commonly includes age-associated memory impairment (AAMI), delirium, depression, schizophrenia, chronic alcoholism, and mental retardation. AAMI is a normal aging process with gradual memory loss in absence of dementia or medical conditions. Delirium has a subacute onset with hallucinations, delusions, and psychomotor agitation (Chapter 4.3). Common causes include infection (urinary tract infection, pneumonia), electrolyte imbalance, hypoglycemia, hepatic or renal dysfunction, endocrine abnormalities (thyroid), and medications or toxins (anticholinergics, benzodiazepines, narcotics).


References

1. Richards SS, Hendrie HC. Diagnosis, management, and treatment of Alzheimer dementia. Arch Intern Med 1999;159:789–798.

2. Crevel HV, van Gool WA, Walstra GJM. Early diagnosis of dementia: which tests are indicated? What are their costs? J Neurol 1999;246:73–78.

3. Weiner MF, ed. The dementias, diagnosis, management and research, 2nd ed. Washington, DC: American Psychiatric Press, Inc., 1996.

4. Kaye JA. Diagnostic challenges in dementia. Neurology 1998;51(Suppl):S45–S52.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Syncope: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

What are the essential aspects to cover?

A. General: mental status, temperature, hydration status, pallor, or cyanosis.

 B. Vital signs: tachycardia, bradycardia, irregularity, or orthostatic hypotension.

 C. Cardiovascular: heart sounds, murmurs, bruits, edema, rales, and pulses.

 D. Neurologic: cranial nerves, reflexes, strength and sensation, tremor, Romberg’s sign, gait, and cerebellar signs.

Testing.

Which tests are useful in diagnosing syncope?

 A. Electrocardiogram (ECG). The most important single initial test to evaluate syncope is the ECG; it is easy and inexpensive and can quickly identify life-threatening arrhythmias or ischemia. Although the diagnostic yield is only 5% (3), if the ECG is normal, ischemia, arrhythmias, and organic heart disease are very unlikely (5). If the ECG is abnormal but does not clearly demonstrate a likely cause for syncope (complete heart block or runs of ventricular tachycardia, for example), other tests are needed to clarify the underlying problem that may be related to the syncope. The result of the ECG, therefore, helps to direct the course of further workup.

 B. Cardiac monitors

 1. Holter monitor or telemetry performed for 24 hours. For patient with organic heart disease, this gives a diagnostic yield of from 2% for arrhythmias correlated to symptoms to 21% with unrelated arrhythmias. Extending this monitoring to 72 hours is not useful (5).

 2. A loop event monitor is a portable, prolonged ambulatory event recorder indicating if there is recurrent syncope and no organic heart disease (yield = 24% to 47%) (4).

 C. Electrophysiologic studies. This invasive cardiac monitoring and arrhythmia induction procedure gives a 50% diagnostic yield for those with organic heart disease or abnormal ECG (compared with 10% if no organic heart disease) (4). This is considered the gold standard for arrhythmia diagnosis but it is expensive and invasive. Powerful predictors of a positive test are an ejection fraction less than 40%, bundle branch block, or atrial fibrillation (5).

 D. Tilt table testing is indicated for unexplained, recurrent syncope when arrhythmia or organic heart disease is excluded and neurocardiogenic syncope is suspected. In this setting, the sensitivity is 67% to 83% and specificity is 90% (4).

E. Echocardiogram and stress tests are used only to evaluate exertional symptoms (echo first in this case) or suspected organic heart disease.

F. Computed tomography scan is used to evaluate focal neurologic signs.

G. Electroencephalogram is indicated for seizure activity only (Chapter 4.7).

H. Carotid massage. Consider this if the patient is aged more than 60 years with unexplained syncope. Perform in the clinic if no bruits, ventricular tachycardia, recent stroke, or myocardial infarction.

I. Blood tests, including hematocrit, serum chemistries, and pregnancy test, are not for screening; order only if a specific medical condition is suspected.

J. Psychiatric evaluation is useful in the setting of a high recurrence rate in a young patient without resultant injuries and no evidence of organic heart disease.

Diagnostic assessment.

 The keys to the diagnosis of syncope are the history, physical examination, and ECG, yielding a diagnosis 45% of the time. The history and physical should focus on cardiac, neurologic, and medication-related issues. Directed testing can add 8% to diagnosis (3). Further classification by age and presence of organic heart disease can help focus evaluation and treatment. If organic heart disease is present or the ECG is abnormal, inpatient telemetry monitoring and electrophysiologic studies are recommended. If organic heart disease is not evident, ambulatory loop ECG and psychiatric evaluations are indicated, as well as possible tilt table testing (4).

Although most syncope patients can be evaluated in the outpatient setting, hospitalization is recommended for those with organic heart disease, chest pain, a history or suspicion of arrhythmia, or presence of neurologic symptoms or signs suggesting transient ischemic attack or stroke. The extent of severity of the organic heart disease is the key determinant of mortality and should direct evaluation and therapy (2). Despite extensive evaluation and testing, the diagnosis may still be elusive in approximately 40% of patients with recurrent syncope, but fortunately these patients have a low incidence of morbidity and mortality.


References

1. Grubb BP, Kosinski D. Neurocardiogenic syncope and related syndromes of orthostatic intolerance. Cardiology in Review 1997;5:182–190.

2. Kapoor WN, Hanusa BH. Is syncope a risk factor for poor outcomes? Comparison of patients with and without syncope. Am J Med 1996;100:646–655.

3. Linzer M, Yang EH, Estes NA 3rd, et al. Clinical guideline: diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Ann Intern Med 1997;126:989–996.

4. Linzer M, Yang EH, Estes NA 3rd, et al. Clinical guideline: diagnosing syncope. Part 2: Unexplained syncope. Ann Intern Med 1997;127:76–86.

5. Meyer MD, Handler J. Evaluation of the patient with syncope: an evidence based approach. Emerg Med Clin North Am 1999;17:189–201.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Delirium: Physical examination.
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Because of the fluctuating nature of delirium, serial examinations are valuable.

 A. Mental status. Observe the patient and take note of changes of level of consciousness, orientation, agitation, combativeness, hallucinations, or inability to concentrate. Evaluate the mental status by using the Mini Mental Status Examination (4) or a similar tool to standardize the findings (Chapter 4.5).

 B. Physical status. Obtain vital signs and evaluate for clinical signs of dehydration, malnutrition, urinary retention, or fecal impaction. The physical examination should be guided by the history, keeping in mind the multifactorial nature of delirium. Evaluate for signs of infection, look for cardiopulmonary decompensation, and complete a thorough neurologic examination with special attention to identifying any focal neurologic deficit.

Testing

 A. Laboratory. All patients should have a complete blood count, serum chemistries including electrolytes, hepatic and renal function, albumin and calcium, and a urinalysis. Additional studies will be directed by clinical suspicions based on the history and the physical examination. These may include thyroid studies, serum medication levels, serum and urine drug screens, lumbar puncture with spinal fluid studies, HIV status, syphilis test, vitamin B12 and folate levels, or serum markers of cardiac damage such as creatine kinase-MB or troponin.

 B. Additional studies. All patients should have an electrocardiogram and a chest roentgenogram as well as arterial blood gases or oxygen saturation level tests. With no history of trauma or focal neurologic deficit, a computed tomography scan is of limited value. An electroencephalogram is also of limited value unless the diagnosis of seizure is being considered.

Diagnostic assessment.

 Delirium can be a medical emergency, and a high index of suspicion must be maintained to accurately diagnose and treat the condition. Diagnosis is complicated by the similarity of presentation of depression, dementia and delirium, and by overlapping signs and symptoms. It is essential to rule out an underlying dementia or depression before the diagnosis of delirium can be made. This has particular impact on the treatment and prognosis of the illness.

 A. Dementia is characterized by a gradual onset of decreased functioning in the areas of memory, execution of the activities of daily living, and social functioning. It is less likely for delirium to cause changes in sensorium, cognition, attention; it is also less likely for delirium to fluctuate from hour to hour. Delirium can coexist with an underlying dementia and should always be considered when a previously diagnosed dementia patient exhibits an acute change in mental status.

B. Depression is characterized by a depressed mood with psychomotor retardation or agitation. Look for a gradual onset of anhedonia, sleep disturbances, fatigue, feelings of guilt or worthlessness, or a previous history of depression (Chapter 3.3).

 C. Other diagnoses. Consider in the differential diagnosis functional psychosis and bipolar disease, especially the manic phase. Both can produce hallucinations, although those of delirium tend to be visual or tactile, whereas those of psychosis tend to be auditory in nature. Epilepsy, especially temporal lobe seizures, can mimic delirium. Multi-infarct dementia, with its characteristic labile emotional state, must be considered. Remember that delirium is a complex, multifactorial condition and can present superimposed on a variety of other medical psychiatric conditions. A careful history and physical examination will help clarify the diagnosis and guide the physician and patient toward the correct treatments.


References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994:129–133.

2. Johnson JC. Delirium in the elderly. Emerg Med Clin North Am 1990;8:255–265.

3. American Psychiatric Association Practice Guidelines. Am J Psychiatry 1999;
156:S1–S20.

4. Folstein MF, Folstein SE, McHugh PR. Mini-mental status examination: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–198.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Dementia: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Many patients are concerned about age-related forgetting of details, a normal phenomenon. This usually results from decreased attention. The fact that they recognize and worry about this distinguishes them from patients with early dementia. Normal forgetting preserves vocabulary and spelling and improves with cues. For example, patients with Alzheimer disease cannot recall a list of related words any better than random words. Patients with dementia on the other hand have difficulty with one or more of the following: learning and retaining new information (e.g., remembering events); handling complex tasks (e.g., balancing a checkbook); reasoning (e.g., inability to cope with unexpected events); spatial orientation (e.g., getting lost in familiar places); language (e.g., word finding); and/or behavior.

Subtle impairments in memory, attention, and concentration are often easily compensated for and therefore hard to pinpoint. Impaired judgment and abstraction on increasingly simple matters and personality changes (notably irritability) are usually noted first. The time course of onset is helpful in distinguishing dementia from delirium, but acute exacerbations of an underlying dementia that mimic delirium are common with drugs and acute physical illness.

The Mini Mental State Exam (MMSE) measures across domains of cognitive function: memory, executive function, attention, language, praxis, and visuospatial ability. A total score of less than 24/30 suggests dementia or delirium. Scores of 20 to 24 suggest mild impairment; 16 to 19, moderate; and 15 or below, severe. It also provides a quantitative assessment useful in following the course of the disease or response to therapy.

Mini-Cog Repeat three objects, Clock Drawing Test (hands at 8:20), then recall three objects. Suggestive of dementia when either 0/3 objects are recalled or when 1 to 2 are missed and CDT is abnormal.

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Source: Field Guide to Bedside Diagnosis, 2007

Syncope: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

The cause of syncope is usually evident after a careful history and physical exam. Identification of a cardiac cause is critical because it portends a poor prognosis (1-year mortality 18% to 33%). In patients with heart disease, the most specific predictors of a cardiac cause are syncope in the supine position or during effort, blurred vision, and convulsive syncope. In patients without heart disease, palpitations are the only significant predictor of a cardiac cause.

Focus on preceding events and witness description. Sudden loss of consciousness without warning is usually due to an arrhythmia. Syncope with chest pain mandates that aortic dissection, myocardial infarction, and pulmonary embolism be ruled out. Syncope with exertion suggests aortic stenosis, hypertrophic obstructive cardiomyopathy, or bradycardia. Events after the syncope, such as confusion, lethargy, or neurological symptoms suggest a seizure.

Consider syncope as the cause of unexplained trauma such as hip fracture or MVA.

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Source: Field Guide to Bedside Diagnosis, 2007

Delirium/Hallucinations: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Delirium is characterized by gross disorientation in the presence of alertness and vigilance, disorders of perception with vivid illusions, and psychomotor and autonomic hyperactivity. It usually develops over a short time and is associated
with fluctuating mental status, decreased attention, disorganized thinking as indicated by rambling, irrelevant, or incoherent speech, and a decreased level of consciousness. The most sensitive findings are variability in level of arousal, impaired short-term memory (e.g., digit span), and disorientation to time. Relatives or friends are helpful sources of information about the tempo and degree of impairment.

Fever, tachycardia, or hypertension should prompt a careful evaluation for a medical cause. Infection is a common cause in the elderly, especially pneumonia or urinary tract infection. Visual hallucinations are organic in origin, due to factors such as drugs, rather than due to schizophrenia.

Confusion Assessment1) Change in mental state (from baseline) that is acute and fluctuates. 2) Difficulty focusing attention or trouble keeping track of what is said. 3) Disorganized thinking (rambling or irrelevant conversation, unpredictable switching between subjects, illogical flow of ideas). 4) Altered level of consciousness (lethargy, stupor, or hyperalert). A positive test requires 1 and 2 positive, and either 3 or 4.

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Source: Field Guide to Bedside Diagnosis, 2007

Agitation: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Perform a complete physical examination. Check for signs of drug abuse, such as needle tracks and dilated pupils. Obtain baseline vital signs and neurologic status for future comparison.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Confusion: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Perform an assessment to determine the presence of systemic disorders. Check vital signs, and assess the patient for changes in blood pressure, temperature, and pulse. Next, perform a neurologic assessment to establish the patient’s level of consciousness.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Level of consciousness, decreased: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Decreased LOC can result from a disorder affecting virtually any body system. After performing a complete neurologic examination, let the results of your history guide the rest of your physical assessment.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Seizures, complex partial: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient has had a seizure, examine him for injury. Make sure he has a patent airway, and then perform a complete neurologic assessment.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Syncope: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Take the patient’s vital signs and examine him for any injuries that may have occurred during his fall. Then perform a complete cardiac and neurologic assessment.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Syncope and Dizziness: Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • Neurocardiogenicsyncope, vascular syncope, breath-holding, hyperventilation, and psychologicdisturbances can usually be distinguished by history and physicalexam.
  • If syncopal episode occurs on assumingupright posture, BP should be measured in supine and upright positions.Postural difference in systolic pressure of >15 mm Hg confirmsdiagnosis of orthostatic syncope.
  • Individuals with recurrent syncope,family history of sudden death, or syncope occurring during intensiveexercise need further evaluation.

  • If recurrent syncope occurs, tilt testingmay determine whether syncope is neurocardiogenic.
  • Family history of syncope and suddendeath suggests hypertrophic cardiomyopathy or long QT interval syndrome.
  • Syncope during intense exercise mayoccur with hypertrophic cardiomyopathy, severe aortic stenosis,anomalous left coronary artery from pulmonary artery, primary pulmonaryhypertension, or exercise-induced atrial fibrillation associatedwith WPW syndrome.
  • Diagnosis of cardiac disorders canbe made from history, physical exam, chest radiograph, ECG, and2-D echocardiogram. Cardiac catheterization and angiography maybe necessary to make definitive diagnosis and to determine severityof lesion. Arrhythmia may be suspected from history, and routine ECGwith rhythm strip may be diagnostic. Otherwise, further testingmay be needed (e.g., Holter monitoring, maximal exercise testing,event recorder or implanted loop recorder monitoring, and electrophysiologictesting).
  • With syncopal episode of unknown cause,ECG should be initially performed searching for WPW syndrome, longQT interval syndrome, or LV hypertrophy with T-wave changes indicativeof cardiomyopathy.

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Agitation: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Determine the severity of the patient's agitation by examining the number and quality of agitation-induced behaviors, such as emotional lability, confusion, memory loss, hyperactivity, and hostility. Obtain a history from the patient or a family member, including diet, known allergies, and all medications, including the use of herbal medicine. Also ask the patient about substance abuse.

    Ask if the patient is being treated for any illnesses. Has he had any recent infections, trauma, stress, or changes in sleep patterns? Observe the patient for signs of substance abuse, such as needle tracks, dilated pupils, jaundiced skin, or abdominal ascites. Ask him about alcohol intake. Obtain the patient's baseline vital signs and neurologic status for future comparison.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Confusion: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    When you take his history, ask the patient to describe what's bothering him. He may not report confusion as his chief complaint, but may suffer from memory loss, persistent apprehension, or the inability to concentrate. He may be unable to respond logically to direct questions. Check with a family member or friend about its onset and frequency. Find out, too, if the patient has a history of head trauma or a cardiopulmonary, metabolic, cerebrovascular, or neurologic disorder. Which medications is he taking, if any? Ask about any changes in eating or sleeping habits and in drug or alcohol use.

    Perform an assessment to determine the presence of systemic disorders. Check the patient's vital signs, and assess him for changes in blood pressure, temperature, and pulse.

    Next, perform a neurologic assessment to establish the patient's level of consciousness.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Level of consciousness, decreased: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Try to obtain history information from the patient, if he's alert, and from his family. Did the patient complain of a headache, dizziness, nausea, vision or hearing disturbances, weakness, fatigue, or other problems before his LOC decreased? Has his family noticed changes in the patient's behavior, personality, memory, or temperament? Also ask about a history of neurologic disease, cancer, or recent trauma or infections; drug and alcohol use; and the development of other signs and symptoms.

    Because a decreased LOC can result from a disorder affecting any body system, tailor the remainder of your evaluation according to the patient's associated symptoms.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Seizures, complex partial: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you witness a complex partial seizure, never attempt to restrain the patient. Instead, lead him gently to a safe area. (Exception: Don't approach him if he's angry or violent.) Calmly encourage him to sit down, and remain with him until he's fully alert. After the seizure, ask him if he experienced an aura. Record all observations and findings. Obtain a history. Has the patient experienced a seizure in the past? Has he had a recent head injury? Has he experienced any fever, headaches, or periods of confusion? Obtain a complete drug history. Take his vital signs and perform a complete neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Syncope: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient reports a fainting episode, gather information about the episode from him and his family. Did he feel weak, light-headed, nauseous, or sweaty just before he fainted? Did he get up quickly from a chair or from lying down? During the fainting episode, did he have muscle spasms or incontinence? How long was he unconscious? When he regained consciousness, was he alert or confused? Did he have a headache? Has he fainted before? If so, how often does it occur? Obtain a complete drug history.

    Next, take the patient's vital signs and examine him for any injuries that may have occurred during his fall. Place him on a cardiac monitor and assess his heart rhythm for abnormalities. Assess cardiac and respiratory status. Monitor pulse oximetry. Perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Diagnosis of Delirium

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