Diseases » Delirium tremens » Diagnosis

Diagnosis of Delirium tremens

Delirium tremens Diagnosis: Book Excerpts

• Ask the following questions - DELIRIUM
• Ask the following questions - DEMENTIA
• Ask the Following Questions - HALLUCINATIONS
• Differential Diagnosis - Delirium
• Differential Diagnosis - Dementia
• Differential Diagnosis - Hallucinations
• Differential Diagnosis - Delirium
• Differential Diagnosis - Hallucinations
• Approach to the Diagnosis - DELIRIUM
• Approach to Diagnosis - HALLUCINATIONS
• Approach to the Diagnosis - MEMORY LOSS AND DEMENTIA
• History and physical examination - Level of consciousness, decreased
• History and physical examination - Agitation
• History and physical examination - Confusion
• Diagnosis - Alcohol-related disorder
• History and physical examination - Level of consciousness, decreased
• History and physical examination - Agitation
• History and physical examination - Confusion
• History - Confusion
• History - Delirium
• History. - Dementia
• Differential Overview - Dementia
• Differential Overview - Delirium/Hallucinations
• History - Level of consciousness, decreased
• History - Level of consciousness, decreased
• History - Agitation
• History - Confusion
• History and physical examination - Level of consciousness, decreased
• History and physical examination - Agitation
• History and physical examination - Confusion
• Approach to the Diagnosis - HALLUCINATIONS
• Approach to the Diagnosis - MEMORY LOSS AND DEMENTIA
• Approach to the Diagnosis - DELIRIUM

Diagnostic Tests for Delirium tremens: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Delirium tremens.

DELIRIUM: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there associated fever? Delirium with fever may simply indicate a self-limited infectious process, but it should bring to mind encephalitis and meningitis as well as cerebral abscess and cerebral hemorrhage.
2. Is there a history of trauma? A history of head trauma would make one suspect a subdural or epidural hematoma and concussion.
3. Is there a history of drug or alcohol ingestion? This is probably the most important single question to ask in the average case coming into the emergency room these days without a good history. Very often, the problem is alcoholism or various popular drugs such as cocaine, lysergic acid diethylamide (LSD), and phencyclidine (PCP).
4. Are there focal neurologic signs? Focal neurologic signs along with the delirium would make one think of subdural or epidural hematoma, cerebral abscess, or cerebral hemorrhage. Remember, a cerebral thrombosis or embolism may present with delirium also.
5. Is there nuchal rigidity? If there is nuchal rigidity, the patient may have meningitis or subarachnoid hemorrhage.
6. Is there a sweet odor to the breath? A sweet odor to the breath should make one think of diabetic coma or alcoholism.
7. What is the response to intravenous thiamine? If the patient responds to intravenous thiamine, the diagnosis is usually Wernicke's encephalopathy or Korsakoff's syndrome.
8. Intermittent delirium should suggest psychomotor epilepsy and transient global amnesia.

DIAGNOSTIC WORKUP

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.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

DEMENTIA: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there a history of drug or alcohol ingestion? Chronic barbiturate intoxication, ergotism, and other psychotropic or antidepressant drugs may cause dementia. Alcoholism may cause dementia in the form of Korsakoff's psychosis or Wernicke's encephalopathy.
2. Is there headache, papilledema, or focal neurologic signs? The most important condition to rule out in this category would be a space-occupying lesion, but normal pressure hydrocephalus, cerebral arteriosclerosis, acute cerebrovascular accident, and general paresis may present with focal neurologic signs.
3. Is there a response to niacin, thiamine, vitamin B ₁₂ , or thyroid? Response to these drugs would indicate that the patient has pellagra, Korsakoff's psychosis, pernicious anemia, or myxedema. However, laboratory tests should be done before administering the medications. Laboratory tests include serum B ₁₂ and folic acid, and a thyroid profile. Unfortunately, most laboratories do not have a test for niacin or thiamine.
4. Is there insight? In patients with cerebral arteriosclerosis, the patient notices that his memory is slipping. This is also true of acquired immunodeficiency syndrome (AIDS).
5. Are there extrapyramidal tract signs? Extrapyramidal tract signs should suggest Huntington's chorea or Parkinson's disease.
6. Are there pyramidal tract signs or myoclonus? Pyramidal tract signs are seen in general paresis and Jakob-Creutzfeldt syndrome, but also myoclonus is seen in Jakob-Creutzfeldt syndrome.

DIAGNOSTIC WORKUP

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.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

HALLUCINATIONS: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there a history of drug or alcohol ingestion? Hallucinations are common during alcohol withdrawal but also may be noted in cocaine addiction, marijuana addiction, LSD intoxication, and PCP intoxication.
2. Are the hallucinations primarily visual in nature? This would suggest an organic cause such as organic brain syndrome, epilepsy, brain tumor, etc.
3. Are the hallucinations episodic? If the hallucinations occur in episodes with normal behavior in between, one should consider epilepsy or narcolepsy.
4. Are the hallucinations associated with early stages of falling asleep or awakening? These types of hallucinations are called hypnogogic and are common in narcolepsy but may also be seen in normal people.
5. Are the hallucinations primarily auditory in nature? This is the type of hallucination most commonly associated with schizophrenia.

DIAGNOSTIC WORKUP

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.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Delirium: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Dementia
• Medical etiologies
  –Infections (e.g., UTI, pneumonia, encephalitis, meningitis)
  –Drug toxicity, including alcohol
  –Drug withdrawal (especially benzodiazepines)
  –Fluid, electrolyte, and metabolic disorders (e.g., hyponatremia, hypoglycemia, hypercalcemia, uremia, hypercarbia)
  –CHF
  –Hypoxia (multiple causes, including CHF)
  –Medications (e.g., antiarrhythmics, antidepressants, neuroleptics, analgesics, GI medications)
  –Stroke
  –Cerebral ischemia (multiple causes)
  –Complex partial seizure disorder is associated with an alteration of awareness
  • Psychiatric etiologies
    –Depression
    –Psychotic illness
    –“Sundowning”: Behavioral deterioration occurs during evening hours (typically occurs in demented institutionalized patients)

  Workup and Diagnosis

  • History should include evaluation of memory difficulties, disorientation, incoherent speech, and level of attention, and a discussion with patients’ family caregivers
    –Risk factors include advanced age, cognitive impairment (including dementia), psychiatric conditions, and severe chronic medical illness
    –Mini-mental status examination
  • Physical examination should include vitals, state of hydration, infectious foci, and neurologic exam, with complete investigation into possible medical etiologies
  • Initial labs may include serum electrolytes, BUN/creatinine, glucose, calcium, magnesium, CBC, and urinalysis
  • Pulse oximetry and/or arterial blood gas may be indicated to screen for hypoxia and/or hypercarbia
  • Thyroid function tests and vitamin B₁₂/folate levels
  • Imaging studies (e.g., head CT, chest X-ray), blood and urine cultures, and/or lumbar puncture may be indicated
  • EEG is indicated if suspect seizure disorder
    –Slowing of α rhythms and unusual slow-wave activity are common in delirium

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Dementia: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Alzheimer's disease is the most common cause of dementia
• Lewy body dementia
• Multi-infarct dementia
• Parkinson's disease
• Alcohol/drugs
• Vitamin deficiency (B₁₂, thiamine)
• CNS infections
  –HIV encephalitis
  –Meningitis
  –Herpes encephalitis
  –Creutzfeldt-Jacob disease
  –Cerebral abscess
  –Neurosyphilis
• Depression (pseudodementia)
• Head trauma
• Pick's disease
• Chronic subdural hematoma
• Huntington's disease
• Chronic hydrocephalus
• Paraneoplastic encephalitis
• Hypothyroidism
• Cerebral vasculitis
• Systemic lupus erythematosus (lupus cerebritis)
• Wilson's disease
• Chronic hypoglycemia or hypocalcemia
• Uremic encephalopathy
• Dialysis dementia
• Multiple sclerosis
• Hydrocephalus
• Postanoxic dementia

Workup and Diagnosis

• Important to distinguish dementia from delirium (acute metabolically induced state of fluctuating consciousness) and depression
• A complete history and physical are essential to rule out underlying medical, neurologic, or psychiatric illnesses that may mimic symptoms of dementia
  –Mini-mental status exam
  –Medication history should be elicited to identify drugs that may contribute to cognitive changes (e.g., analgesics, sedatives, anticholinergics, antihypertensives)
  • Labs may include CBC, electrolytes, calcium, BUN/creatinine, liver function tests, glucose, thyroid function tests, vitamin B₁₂ and folate, screening for inflammatory/infectious causes, and toxicology screen
  • CT without contrast to rule out structural lesions (e.g., infarct, malignancy, hydrocephalus, extracerebral fluid collection)
  • EEG is not routinely used; however, it may identify toxic/metabolic disorders or Creutzfeldt-Jakob disease
  • Genetic testing may be indicated if family history suggests Alzheimer's disease (especially early-onset)
    –Mutations of chromosomes 1, 14, 21
    –Increased frequency of apolipoprotein ∊ 4 allele
    • CSF analysis may be useful in some cases
    • HIV and syphilis (RPR) testing if known risk factors

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Hallucinations: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Delirium
  –Develops over hours to days
  –Fluctuates throughout the day
  –Causes include dehydration, drug-induced, electrolyte imbalance, UTI, URI, hypoglycemia, and alcohol or drug withdrawal
  –Occurs in 10–30% of hospital patients
  –Drug-induced delirium (e.g., cocaine, β-blockers, alcohol, corticosteroids, pseudoephedrine, dopaminergic drugs)
• Alcohol withdrawal (delirium tremens)
  –Often presents in hospitalized patients about 3 days after admission
  –Commonly presents with tactile hallucinations (e.g., formication—the sense of insects crawling over body)
  –May be accompanied by seizure activity
• Hallucinogenic syndromes (e.g., LSD, marijuana, mescaline, phencyclidine, mushrooms, amphetamines)

• Schizophrenia
  –Auditory hallucinations are most frequent; visual hallucinations occur in about 50% of patients, tactile in 20%, olfactory in 6%
  –Progresses to positive psychotic symptoms (e.g., hallucinations, delusions, thought disorder) and/or negative symptoms (e.g., anhedonia, poor concentration, flattened affect, poor social/personal function)
  –1% incidence in the general population, males >females

• Schizophreniform disorder
• Schizoaffective disorder
• Post-traumatic stress disorder
• Dementia
• Systemic lupus erythematosus
  –Auditory hallucinations caused by corticosteroids; visual and tactile by lupus psychosis
• Bipolar disorder
• Psychotic depression
• Postpartum major depression
• Mass lesions
• CNS infections/encephalitis
• Seizures
• Occipital lobe injury
• Heavy metal ingestion
• Lewy body dementia

Workup and Diagnosis

• History and physical examination
  –In caring for patients with major psychiatric illness, follow three important principles: Know the patient's drug regimen, work with psychiatrist if changes are needed, and remember that chronic psychiatric patients have difficulty communicating medical history and needs
  –Diagnosis of schizophrenia requires two positive or negative symptoms present for 1 month and signs continuing for at least 6 months (DSM-IV criteria)
  –Assess for suicidal/homicidal ideations
  –Note timing of hallucinations (e.g., following alcohol or drug use, at random, under stress)
• Initial labs may include electrolytes, glucose, calcium, BUN/creatinine, albumin, liver function tests, alkaline phosphatase, magnesium, phosphate, CBC, ECG, pulse oximetry, urinalysis, toxicology screen, and drug levels
• Chest X-ray may be indicated for infectious etiologies of delirium; lumbar puncture may be indicated
• Further tests, if delirium is suspected, include vitamin B₁₂ and folate levels, ANA, ammonia, and heavy metal screen
• EEG may reveal slowing activity in delirium, low-voltage fast activity in alcohol withdrawal
• Psychiatric consult after medical causes of psychosis are ruled out

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Delirium: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Acute systemic infection
  –May be viral or bacterial cause
  –Often associated with high fever
• Hypoglycemia, diabetic ketoacidosis
• Central nervous system infection
  –Meningitis, encephalitis, brain abscess

• Drugs
  –Alcohol: Acute intoxication
  –Amphetamines: Also tremors, dry mouth, tachycardia, hyperactivity
  –Hallucinogens (LSD, mescaline, PCB) also tremors, dilated pupils, nausea, and abdominal pain
  –Phencyclidine (a.k.a. Angel Dust) with atxia, nystagmus, hyperreflexia, and hypertension
  –Opiates: Also with pinpoint pupils
  –Antihistamines
  –Phenothiazines
  –Organic solvents
  –Salicylates
  –Glucocorticoids

• Head injury
• Rocky Mountain spotted fever (RMSF)
  –Delirium and hallucinations may precede rash; fever, headache, myalgias, chills
• Malaria
• Rabies
• Syphilis
  –Tertiary syphilis is rare in children
• Hyponatremia
• Uremia
• Migraine
• Hypoxia
• Heat stroke
• Hepatic failure
• Systemic lupus erythematosus
  –Delirium is due to cerebral vasculitis
• Pellagra
  –Due to niacin deficiency
  –Also with diarrhea, dermatitis, dementia
• Hartnup disease
  –Rash, ataxia, psychological disturbance
  –Symptoms may be intermittent
• Porphyria
  –Attacks of abnormal behavior do not begin until late adolescence

Workup and Diagnosis

• History
  –Duration of delirium
  –Exposure to excessive heat
  –Ingestion of drugs
  –Associated signs and symptoms (fever, diarrhea, vomiting, rashes, sweating)
  –Recent head trauma
  –Unusual or fad diets (diets that are mainly corn-based can lead to pellagra)

• Physical exam
  –Vital signs
  –Pupil size and reactivity
  –Nuchal ridgidity, Kernig and Brudzinski sign
  –Head exam for signs of trauma
  –Scaling rashes (pellagra), petechiae of palms and soles (RMSF), sun sensitivity scars (porphyria)
  –Ataxia, asterixis (flapping at wrists with uremia)
• Labs
  –All patients should have a glucose measurement
  –Strongly consider toxicology evaluation for all patients (typically do both blood and urine)
  –Serum electrolytes, BUN, creatinine
  –Liver testing (ALT, AST, bilirubin, PT/PTT)
  –Specific testing of enzyme levels (porphyries), urinary amino acids (Hartnup disease), niacin levels (pellagra)
  • Studies
    –Consider LP and head imaging (CT or MRI)

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Hallucinations: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Hallucinogenic drugs
  –LSD, “mushrooms,” mescaline, and PCP are primarily hallucinogens
  –Amphetamines, cocaine, inhalants, and marijuana may also produce hallucinations
• CNS acute events
  –Trauma
  –CNS infection
  –Hypoxic events

• Psychosis
  –Defined as a mental state with significant impairment in cognition, interpersonal relations, and reality testing
  –Hallucinations may be a major or minor component
  –Psychosis may be psychiatric or organic (secondary to CNS insult)

• Schizophrenia
  –A disorder of impaired perception, cognition, interpersonal relations, and behavior with illogical and disordered thought content
  –Hallucinations (most often auditory) and delusions are common findings
  –Onset is frequently in adolescence
  –Frequently a positive family history

• Seizure disorders
  –Prominent auras may manifest as perceptual disturbances; visual and olfactory are the most common; tactile may also occur
• Narcolepsy
  –Hypnagogic hallucinations are hallucinations that occur while falling asleep; they may be visual or auditory
• Medications
  –Antipsychotics, anticholinergics, and corticosteroids can rarely cause hallucinations

Workup and Diagnosis

• History
  –History of mental illness
  –Recent behavioral patterns including relationships, self-care, and school performance
  –Medication and illicit drug use
  –Trauma, CNS infection, hypoxic episodes
  –Family history of mental illness

• Physical exam
  –Vital signs: Hallucinogens, amphetamines, and cocaine may cause tachycardia, hypertension, and hyperthermia
  –Hallucinogens, amphetamines, and cocaine may also cause pupillary changes, tremor, ataxia, arrhythmia, and hyperreflexia

• Mental status exam
  –Orientation and general appearance
  –Long- and short-term memory
  –Affect and behavior
  –Thought processing and content
  –Speech and language
• Labs
  –Urine and serum toxicologic screen
• Studies
  –Cranial imaging is most useful when there is a history of head trauma
  –EEG for patients in whom a seizure is suspected

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

DELIRIUM: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

It is essential to get a history of drug or alcohol use from the patient or family and a drug screen may be done in most cases. The workup should also include a CBC, sedimentation rate, urinalysis, ANA analysis, chemistry panel, and electrolytes. A CT scan or MRI of the brain will be necessary in most cases. It may be wise to administer intravenous thiamine and glucose while awaiting the results of blood work. If there is a fever, blood cultures and possibly a spinal tap (after a CT scan or MRI has ruled out a space-occupying lesion) may be indicated. Arterial blood gas analysis and carboxyhemoglobin should be determined. A neurologist or neurosurgeon needs to be consulted early in the workup.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

HALLUCINATIONS: Approach to Diagnosis
(Differential Diagnosis in Primary Care)

In the workup of hallucinations, it is essential to get a drug history from a relative or friend if not from the patient. Ask about a family history of epilepsy or head trauma. A drug screen should be ordered. If there is no mental deterioration, referral to a psychiatrist may be done but an EEG may still be indicated. With mental deterioration, a neurologist should be consulted. When there is doubt about mental deterioration, psychologic testing may be done. CT scans, EEGs, skull x-ray films, and arteriograms may be necessary in selected cases.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

MEMORY LOSS AND DEMENTIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Once again, the presence or absence of other neurologic signs and symptoms is important. If one does not have the skills or the time for a complete neurologic examination, immediate referral is indicated. Next, a careful drug history is done. Withdrawal of all drugs may clear the dementia. An EEG, skull x-ray film, CT scan or MRI, spinal tap (if there is no papilledema), and psychometric tests are basic to any workup. If the CT scan or MRI shows dilated ventricles, a spinal fluid nuclear flow study is indicated to exclude normal-pressure hydrocephalus. In the absence of other neurologic signs and spinal fluid analysis negative for syphilis and other chronic encephalopathies, one should do an endocrine workup and look for systemic diseases such as porphyria. Drug screens for lead intoxication, and bromism should also be performed.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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.

» READ BOOK EXCERPT ONLINE »

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

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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

Alcohol-related disorder: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

For characteristic findings in patients with alcoholism, see Diagnosing substance dependence and related disorders, page 430.

Clinical findings may help support the diagnosis of alcohol-related disorder. For example, laboratory tests can confirm alcohol use and complications and document recent alcohol ingestion. A blood alcohol level ranging from 0.08% to 0.10% weight/volume (200 mg/dl) is accepted as the level of intoxication, depending on the state or country. The blood alcohol level in a physically dependent and tolerant drinker may exceed levels that would cause severe dysfunction or death in a nontolerant drinker. For example, a tolerant drinker might have a blood alcohol level of more than 0.5 mg (the usual lethal level) and still be alive, talking, and moving.

In severe hepatic disease, the blood urea nitrogen level is increased, and the serum glucose level is decreased. Further testing may reveal increased serum ammonia and amylase levels. Urine toxicology studies may help determine if the patient with alcohol withdrawal delirium or another acute complication abuses other drugs as well.

Liver function studies revealing increased levels of serum cholesterol, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and creatine phosphokinase may point to liver damage, and elevated serum amylase and lipase levels point to acute pancreatitis. A hematologic workup can identify anemia, thrombocytopenia, increased prothrombin time, and increased partial thromboplastin time.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

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

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

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

. Collateral information is valuable with confused patients.

 A. Characteristics. Is there an altered level of consciousness? Is so, consider urgent factors. Is the patient easily distractible or having difficulty keeping track of what is said? Is there an altered sleep–wake cycle; do symptoms fluctuate and are there changes in psychomotor behavior? If so, delirium is likely. Is thinking disorganized or incoherent? Is speech rambling, irrelevant, or frequently switching subjects? Is the patient disoriented? Do memory problems exist? Are there perceptual disturbances, including hallucinations or thought broadcasting, insertion, or withdrawal? The presence of visual hallucinations suggests organic causes. Are delusions present? Is there an indifference to the symptoms? If so, consider conversion disorder. Are there nightmares or increased startle response? If so, acute or posttraumatic stress disorders should be considered (Chapter 3.1).

 B. Chronology of symptoms. Is the onset acute? In dementia, a chronic degree of confusion exists; however, acute confusion can herald the onset of delirium, warranting further evaluation (Chapter 4.1). Is the course fluctuating and do symptoms occur more often at night? If so, this suggests delirium. Have such symptoms occurred in the past? If so, what caused them then?

 C. Medical history. Confusion is more likely in patients with multiple medical problems, longer lists of medications, or recent medication changes. Medications that can induce confusion include anticholinergics, sedatives, steroids, metronidazole, and digoxin, among others.

 D. Psychiatric history. Are there any prior diagnoses and treatments, or a psychotropic medication history? If so, do current symptoms match prior psychiatric episodes? If so, consider a psychiatric recurrence. Have there been any recent psychosocial stressors? If so, consider the possibilities of dissociative and stress syndromes. It is important to note that a prior psychiatric history does not necessarily imply the confusion is caused by a psychiatric exacerbation; conversely, the absence of a psychiatric history does not rule out a psychiatric cause. Psychotic disorders tend to occur in younger patients, whereas delirium is more likely in older patients.

 E. Other information. Current or past use of alcohol or drugs, recent injuries (particularly head injuries), and exposure to toxins. A review of systems helps detect organic causes.

Physical examination

 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).

» READ BOOK EXCERPT ONLINE »

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

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

 A. Baseline. Perhaps the most important aspect of taking the patient’s history is establishing the individual’s baseline mental status and level of functioning. In addition to interviewing the patient, family, friends, and acquaintances must be interviewed as well. Other healthcare providers, such as nurses and doctors, who have dealt with the patient previously in an office, nursing home, or hospital setting, can be invaluable sources of information. Try to establish the presence or absence of the signs and symptoms of dementia or depression (section V).

 B. Previous medical history. Look for previously existing medical problems that can precipitate delirium, such as CHF, diabetes, hypothyroidism, benign prostatic hypertrophy or HIV (section I.B). Evaluation of the medications is crucial, including prescription and over-the-counter medications. Is the patient taking them as directed? Is the patient on any medications that could be present in toxic levels (e.g., digoxin, phenytoin or theophylline)? Has there been any recent trauma or surgery? Are there symptoms of infection such as UTI or pneumonia? Be sure to interview friends and family.

 C. Social history. Does the patient have a history of substance abuse? Is the patient currently using any alcohol or illegal substances? When was their last use? Be aware of potential withdrawal. If the patient is abusing alcohol, is there a history of delirium tremors with previous abstinence? Does the patient live alone? Is the patient at risk for poor nutrition?

Physical examination.

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.

» READ BOOK EXCERPT ONLINE »

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

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

A concerned family member will often bring patients into the office when obvious memory impairment occurs. The deficit will be sufficiently obvious to interfere with daily living, work, or social activities. When questioning the reliable historian, ask about the specific cognitive changes (language, judgment, abstract thinking, praxis, visual recognition, and constructional ability). Ask about the duration of symptoms, the mode of onset (insidious or abrupt), and the progression (slow or rapid, gradual or stepwise). Check on general risk factors (e.g., increasing age, atherosclerosis, head trauma, CNS infection), and family history. Specific risk factors for AD include increasing age, lower intelligence, small head size, history of head trauma (4), and Down’s syndrome.

Physical examination.

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.

» READ BOOK EXCERPT ONLINE »

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

Dementia: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Alzheimer disease

❑ Multi-infarct dementia

❑ Depression

❑ Drugs

❑ Parkinson disease

❑ Frontal lobe dementia

❑ Vitamin B₁₂ deficiency

❑ HIV encephalopathy

❑ Korsakoff syndrome

❑ Brain tumor

❑ Normal pressure hydrocephalus

❑ Chronic subdural hematoma

❑ Neurosyphilis

❑ Creutzfeldt-Jakob

❑ Wilson disease

Diagnostic Approach

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.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Delirium/Hallucinations: Differential Overview
(Field Guide to Bedside Diagnosis)

Systemic

❑ Drugs/toxins

❑ Sepsis

❑ Hypoglycemia

❑ Hypercalcemia

❑ Hyponatremia

❑ Shock

❑ Delirium tremens

❑ Vitamin B₁₂ deficiency

❑ Hypoxia

❑ Hypercapnia

❑ Thyrotoxicosis

❑ Uremia

❑ Hepatic encephalopathy

❑ Thiamine deficiency

❑ Heat stroke

❑ Hypothermia

❑ Lead intoxication

❑ Carbon monoxide poisoning

Neurologic

❑ Concussion

❑ Hypertensive encephalopathy

❑ Subdural hematoma

❑ Postictal

❑ Transient global amnesia

❑ Meningitis

❑ Right parietal stroke

❑ Encephalitis

❑ Vasculitis

❑ Carcinomatous meningitis

Hallucinations

❑ Drugs

❑ Schizophrenia

❑ Temporal lobe epilepsy

Diagnostic Approach

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.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Level of consciousness, decreased: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

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.

Physical examination

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. Perform a complete neurologic assessment and a physical assessment. Determine the patient’s baseline Glasgow Coma Scale score and evaluate on an ongoing basis.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

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

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 or cancer; recent trauma or infection; drug and alcohol use; and the development of other signs and symptoms.

» READ BOOK EXCERPT ONLINE »

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

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

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 and known allergies.

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. Ask about alcohol intake.

» READ BOOK EXCERPT ONLINE »

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

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

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 onset and frequency. Find out, too, if the patient has a history of head trauma or a cardiopulmonary, metabolic, cerebrovascular, or neurologic disorder. Find out which medications he’s taking, if any. Ask about any changes in eating or sleeping habits and in drug or alcohol use.

» READ BOOK EXCERPT ONLINE »

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

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

HALLUCINATIONS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

In the workup of hallucinations, it is essential to get a drug history from a relative or friend if not from the patient. Ask about a family history of epilepsy or head trauma. A drug screen should be ordered. If there is no mental deterioration, referral to a psychiatrist may be done but an electroencephalogram (EEG) may still be indicated. With mental deterioration, a neurologist should be consulted. When there is doubt about mental deterioration, psychologic testing may be done. Computed tomography (CT) scans, EEGs, skull x-ray films, and arteriograms may be necessary in selected cases.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

MEMORY LOSS AND DEMENTIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Once again, the presence or absence of other neurologic signs and symptoms is important. If one does not have the skills or the time for a complete neurologic examination, immediate referral is indicated. Next, a careful drug history is done. Withdrawal of all drugs may clear the dementia. An electroencephalogram (EEG), skull x-ray film, computed tomography (CT) scan or magnetic resonance imaging (MRI), spinal tap (if there is no papilledema), and psychometric tests are basic to any workup. If the CT scan or MRI shows dilated ventricles, a spinal fluid nuclear flow study is indicated to exclude normal-pressure hydrocephalus. In the absence of other neurologic signs and negative spinal fluid analysis for syphilis and other chronic encephalopathies, one should do an endocrine workup and look for systemic diseases such as porphyria. Drug screens for lead intoxication and bromism should also be performed.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

DELIRIUM: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

It is essential to get a history of drug or alcohol use from the patient or family, and a drug screen may be done in most cases. Infection is another common cause. The workup should also include a CBC, sedimentation rate, urinalysis, antinuclear antibody (ANA) analysis, chemistry panel, and electrolytes. A CT scan or MRI of the brain will be necessary in most cases. It may be wise to administer intravenous thiamine and glucose while awaiting the results of blood work. If there is a fever, blood cultures and possibly a spinal tap (after a CT scan or MRI has ruled out a space-occupying lesion) may be indicated. Arterial blood gas analysis and carboxyhemoglobin should be determined. A neurologist or neurosurgeon needs to be consulted early in the workup.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Delirium tremens

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Signs of Delirium tremens
• Complications of Delirium tremens
• Misdiagnosis of Delirium tremens
• Undiagnosed Delirium tremens
• Misdiagnosis of Underlying Causes of Delirium tremens

Tools & Services:

• Bookmark this page
• Take a survey relating to Delirium tremens
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

homepage | back to top

Common Health Mistakes

Choose ... Alzheimers & Dementia Asthma Child ADHD ADHD in Adults Allergy Hypertension Bipolar Breast Cancer Celiac Disease Crohns Disease Colon Cancer Contraception Diabetes Cancer Depression Erectile Disorder Cholesterol COPD GERD Heartburn/Reflux Metabolic Syndrome Migraine/Headache Multiple Sclerosis Obesity Osteoporosis Overactive Bladder Psoriasis Sexual Disorder Sleep Disorders Smoking The Pill Ulcerative Colitis All Common Mistakes

Symptom
Checker

Choose... Fever Rash Pain Headache Fatigue Cough Other symptoms

Search Specialists by State and City

Choose... GENERAL PRACTICE CARDIAC HEALTH WOMEN'S HEALTH CANCER CARE RADIOLOGY MENTAL HEALTH PATHOLOGY EAR, NOSE, THROAT MEDICINE GENETICS NEUROLOGY DIALYSIS CARE SURGERY ORTHOPEDICS/SPORTS MEDICINE CHILDREN'S HEALTH OTHER SPECIALTIES