Diagnosis of Dementia
Dementia Diagnosis: Book Excerpts
Tests and diagnosis discussion for Dementia:
DEMENTIA: NWHIC (Excerpt)
Dementia is a clinical diagnosis made by a physician. Although there
are a number of different checklists available, the "Diagnostic and
Statistical Manual-IV" is the most widely accepted list of criteria for
dementia. A patient, who has an acquired problem of memory, cognitive
ability, and problems with functional abilities, may have a dementia
syndrome. The patient must not have a confusional state, such as delirium
or drug intoxication, at the time of diagnosis. A skilled physician can
apply these criteria to detect the presence of dementia, but some
physicians may be far more skilled than others in this regard. (Source: excerpt from DEMENTIA: NWHIC)
Forgetfulness It's Not Always What You Think - Age Page - Health Information: NIA (Excerpt)
People who are worried about memory problems should see their
doctor. If the doctor believes that the problem is serious, then a
thorough physical, neurological, and psychiatric evaluation may be
recommended. A complete medical examination for memory loss may
include gathering information about the person's medical history,
including use of prescription and over-the-counter medicines, diet,
past medical problems, and general health. Because a correct
diagnosis depends on recalling these details accurately, the doctor
also may ask a family member for information about the person.
Tests of blood and urine may be done to help the doctor find any
problems. There are also tests of mental abilities (tests of memory,
problem solving, counting, and language). A brain CT scan may assist
the doctor in ruling out a curable disorder. A scan also may show
signs of normal age-related changes in the brain. It may be
necessary to have another scan at a later date to see if there have
been further changes in the brain.
Alzheimer's disease and multi-infarct dementia can exist
together, making it hard for the doctor to diagnose either one
specifically. Scientists once thought that multi-infarct dementia
and other types of vascular dementia caused most cases of
irreversible mental impairment. They now believe that most older
people with irreversible dementia have Alzheimer's disease.
(Source: excerpt from Forgetfulness It's Not Always What You Think - Age Page - Health Information: NIA)
Diagnosis of Dementia: medical news summaries:
The following medical news items
are relevant to diagnosis and misdiagnosis issues for Dementia:
Diagnostic Tests for Dementia: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Dementia.
AMNESIA:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the amnesia transient or persistent? If it is transient, one should look for evidence of a head injury. If there is no evidence of a head injury, then one should consider epilepsy, transient ischemic attacks, and migraine. If there is evidence of a
head
injury, one would consider concussion and some of the other more serious conditions of the brain that occur with a head injury.
- Is there a fever? If the amnesia is persistent and there is a fever, one needs to consider encephalitis, meningoencephalitis, cerebral abscesses, and encephalomyelitis. If there is no fever, one must ask if there is a reduction of memory for recent events. If there is reduction of memory for recent events, one should consider some of the more serious diseases of the brain, such as cerebral tumors, chronic drug or alcohol use, Alzheimer's disease, cerebral arterial sclerosis, and neurosyphilis. If there is no reduction of memory for recent events, then a psychiatric disorder such as hysteria, dissociated reaction, or schizophrenia must be considered.
DIAGNOSTIC WORKUP
All patients with a history of amnesia deserve a CT scan or magnetic resonance imaging (MRI). The CT scan would be more cost-effective and would be the diagnostic test of choice because it also helps detect acute brain hemorrhages. Patients with fever should have a spinal tap as well as CBC, urinalysis, and chemistry panel. These patients also probably should have a blood culture. An electroencephalogram (EEG) should be ordered to rule out epilepsy and toxic metabolic inflammatory diseases of the brain.
If all these studies are negative and an organic cause is still considered, then referral to a neurosurgeon or neurologist is in order. If these studies are negative and a psychiatric disorder is suspected, a psychiatrist should be consulted.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
DELIRIUM:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- 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.
- Is there a history of trauma? A history of head trauma would make one suspect a subdural or epidural hematoma and concussion.
- 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).
- 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.
- Is there nuchal rigidity? If there is nuchal rigidity, the patient may have meningitis or subarachnoid hemorrhage.
- Is there a sweet odor to the breath? A sweet odor to the breath should make one think of diabetic coma or alcoholism.
- 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.
- 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
HALLUCINATIONS:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- 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.
- Are the hallucinations primarily visual in nature? This would suggest an organic cause such as organic brain syndrome, epilepsy, brain tumor, etc.
- Are the hallucinations episodic? If the hallucinations occur in episodes with normal behavior in between, one should consider epilepsy or narcolepsy.
- 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.
- 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
DEMENTIA:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- 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.
- 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.
- 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.
- 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).
- Are there extrapyramidal tract signs? Extrapyramidal tract signs should suggest Huntington's chorea or Parkinson's disease.
- 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
APHASIA, APRAXIA, AND AGNOSIA:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it intermittent? Episodic aphasia, apraxia, or agnosia would suggest epilepsy, transient ischemic attacks, migraine, or hypertensive encephalopathy.
- Is it acute or gradual in onset? Acute onset of aphasia, apraxia, or agnosia would suggest a cerebral vascular accident, or if there is fever, the onset of a cerebral abscess. It may also mark the onset of acute encephalitis. The gradual onset of aphasia, apraxia, and agnosia would suggest a tumor or other type of space-occupying lesion.
- Is there associated headache or papilledema? Headaches with aphasia, apraxia, and agnosia might suggest migraine, but one should not forget a brain tumor. Obviously, papilledema is a sign of a space-occupying lesion.
- Is there significant dementia? The development of dementia along with the aphasia, apraxia, and agnosia suggest Alzheimer's disease, Pick's disease, herpes encephalitis, multiple sclerosis, or Korsakoff's psychosis.
DIAGNOSTIC WORKUP
All patients should have a CBC, sedimentation rate, chemistry panel, a VDRL test, and a CT scan of the brain. The CT scan may demonstrate an infarct, a space-occupying lesion, a degenerative disease, or multiple sclerosis. If this is negative, a neurologist should be consulted before ordering MRI or a spinal tap.
If the patient presents with intermittent aphasia, apraxia, or agnosia, an EEG should be done to rule out epilepsy, and a carotid scan should be done to rule out carotid stenosis or carotid plaques with ulceration. Four-vessel angiography may need to be considered, but a neurologist should be consulted before this is done.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Amnesia:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Head trauma (e.g., concussion, hemorrhage)
–Usually results in transient retrograde and anterograde amnesia
Alzheimer's disease
–Most common cause of chronic amnesia
Infection
–Herpes simplex encephalitis is a particularly common cause of infectious amnesia, because it has a predilection for the temporal lobes
- Seizure disorders
–Retrograde amnesia is most common after a generalized tonic-clonic seizure during the postictal period
–Some complex partial seizure foci (particularly temporal lobe epilepsy) can also produce “blank” periods of memory
-
Toxicologic insults
–Binge alcohol consumption
–Benzodiazepine use (e.g., “date rape” drug
flunitrazepam, also known as Rohypnol)
-
Psychogenic causes are relatively common, but should be a diagnosis of exclusion
-
Korsakoff's syndrome
-
Transient global amnesia
–A rare, transient, ischemic attack-like condition of proposed vascular etiology
–Causes abrupt onset of short-term memory
loss for minutes to hours
–Typically occurs in patients older than 50
–Seen in patients with migraines
Workup and Diagnosis
-
History and physical examination
–Special attention to neurologic and head examination
–Life-threatening head trauma and CNS infection should
be considered initially in patients with altered mental status and amnesia
Initial labs may include CBC, electrolytes, glucose, calcium, magnesium, phosphorus, coagulation studies, and serum and urine toxicology screens Lumbar puncture with CSF analysis should be considered early if CNS infection is suspected
–Test for opening pressure, appearance (e.g., clear, cloudy, bloody), protein, glucose, CSF-to-serum glucose ratio, Gram stain, culture
–Cryptococcal antigen and acid-fast bacilli smear and culture in patients in endemic areas or with HIV
–If there is a delay in initiating lumbar puncture due to a need for imaging (e.g., head CT to rule out increased intracranial pressure), empiric antibiotics should be administered immediately
-
Head CT without contrast may be needed to exclude bleeding in cases of head trauma, and may also identify structural lesions
-
MRI of the head with diffusion-weighted imaging is more sensitive for diagnosing stroke, tumor, and the subtle white matter changes associated with vascular disease
-
EEG to rule out seizure disorder
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
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
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
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
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
AMNESIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup of amnesia must include a drug screen, CT scan, or magnetic resonance imaging (MRI) and often an electroencephalogram (EEG) to rule out epilepsy. Migraine may ruled out by a careful history. A neurologist or psychiatrist will need to be consulted in most cases. If there is fever, a CBC, chemistry panel, ANA, urinalysis, and blood cultures should be ordered. A spinal tap may be necessary as well.
» 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. 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
Amnesia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Because the patient typically isn’t aware of his amnesia, you’ll usually need help in gathering information from his family or friends. Throughout your assessment, notice the patient’s general appearance, behavior, mood, and train of thought. Ask when the amnesia first appeared and what types of things the patient is unable to remember. Can he learn new information? How long does he remember it? Does the amnesia encompass a recent or remote period?
Test the patient’s recent memory by asking him to identify and repeat three items. Retest after 3 minutes. Test his intermediate memory by asking, “Who was the president before this one?” and “What was the last type of car you bought?” Test remote memory with such questions as “How old are you?” and “Where were you born?”
Take the patient’s vital signs and assess his level of consciousness (LOC). Check his pupils: They should be equal in size and should constrict quickly when exposed to direct light. Also, assess his extraocular movements. Test motor function by having the patient move his arms and legs through their range of motion. Evaluate sensory function with pinpricks on the patient’s skin. (See Amnesia: Common causes and associated findings.)
» 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
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
Dissociative amnesia:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
For characteristic findings in patients with this condition, see Diagnosing dissociative amnesia.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Amnesia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Because the patient often isn’t aware of his amnesia, you’ll usually need help in gathering information from his family or friends. Throughout your assessment, notice the patient’s general appearance, behavior, mood, and train of thought. Ask when the amnesia first appeared and what types of things the patient is unable to remember. Can he learn new information? How long does he remember it? Does the amnesia encompass a recent or a remote period?
Test the patient’s recent memory by asking him to identify and repeat three items. Retest him after 3 minutes. Test his intermediate memory by asking, “Who was the president before this one?” and “What was the last type of car you bought?” Test remote memory with such questions as “How old are you?” and “Where were you born?”
Take the patient’s vital signs and assess his level of consciousness (LOC). Check his pupils: They should be equal in size and should constrict quickly when exposed to direct light. Also, assess his extraocular movements. Test motor function by having the patient move his arms and legs through their range of motion. Evaluate sensory function with pinpricks on the patient’s skin. (See Amnesia: Causes and associated findings.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Apraxia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you detect apraxia, ask about previous neurologic disease. If the patient fails to report such disease, begin a neurologic assessment. First, take the patient’s vital signs and assess his level of consciousness. Be alert for any evidence of aphasia or dysarthria. Ask the patient if he has recently experienced headaches or dizziness. Then test the patient’s motor function, observing for weakness and tremors. Next, use a small pin or another pointed object to test sensory function. Check deep tendon reflexes for quality and symmetry. Finally, test the patient for visual field deficits.
Be alert for signs and symptoms of increased intracranial pressure (ICP), such as headache and vomiting. If you detect these, elevate the head of the bed 30 degrees and monitor the patient closely for altered pupil size and reactivity, bradycardia, widened pulse pressure, and irregular respirations. Have emergency resuscitation equipment nearby, and be prepared to give mannitol I.V. to decrease cerebral edema.
If the patient is experiencing seizures, stay with him and have another nurse notify the physician immediately. Avoid restraining the patient. Help him to a supine position, loosen tight clothing, and place a pillow or other soft object beneath his head. If the patient’s teeth are clenched, don’t force anything into his mouth. If his mouth is open, protect the tongue by placing a soft object, such as a washcloth, between his teeth. Turn the patient’s head to provide an open airway.
After completing the examination and ensuring the patient’s safety, take a history. Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease. Then assess the apraxia further to help determine its type. (See Apraxia: Causes and associated findings, page 72.)
» 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
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).
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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.
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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
Amnesia:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Concussion
❑ Alzheimer disease
❑ Drugs
❑ Generalized seizure
❑ Migraine
❑ Transient global amnesia
❑ Psychogenic
❑ Herpes simplex encephalitis
❑ Complex partial seizures
❑ Korsakoff syndrome
Diagnostic Approach
Amnesia is characterized by an inability to recall prior events and to learn new information, despite a normal level of consciousness. There must be injury to both temporal lobes in order for amnesia to occur.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
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
Apraxia:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Obtain the patient’s history. Ask whether he has a previous history of neurologic disease. Does he have a history of headaches or dizziness?
Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease.
Physical examination
First, obtain the patient’s vital signs and assess his level of consciousness. Perform a neurologic assessment, staying alert for evidence of aphasia or dysarthria. Assess motor function, observing for weakness and tremors. Assist with testing sensory function, deep tendon reflexes, and visual field deficits.
Stay alert for signs and symptoms of increased intracranial pressure (ICP), such as headache and vomiting. If present, elevate the head of the bed 30 degrees and monitor the patient closely for altered pupil size and reactivity, bradycardia, widened pulse pressure, and irregular respirations. Have emergency resuscitation equipment nearby, and be prepared to give mannitol I.V. to decrease cerebral edema after inserting a urinary catheter to avoid bladder rupture.
If the patient is experiencing seizures, stay with him and have another nurse notify the physician immediately. Avoid restraining the patient. Assist him into a supine position, loosen tight clothing, and place a pillow or other soft object beneath his head. Don’t place anything into his mouth. Turn the patient’s head to the side to provide an open airway.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 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
Apraxia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If you detect apraxia, ask about previous neurologic disease. Ask the patient if he has recently experienced headaches or dizziness. Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease. Then assess the apraxia further to help determine its type.
» 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
(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
Amnesia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Because the patient typically isn't aware of his amnesia, you'll usually need help in gathering information from his family and friends. Throughout your assessment, notice the patient's general appearance, behavior, mood, and train of thought. Ask when the amnesia first appeared and what the patient is unable to remember. Can he learn new information? How long does he remember it? Does the amnesia encompass a recent or remote period?
Test the patient's recent memory by asking him to identify and repeat three items. Retest after 3 minutes. Test his intermediate memory by asking, “Who was the president before this one?” and “What was the last type of car you bought?” Test remote memory with such questions as “How old are you?” and “Where were you born?”
Take the patient's vital signs and assess his level of consciousness (LOC). Check his pupils: They should be equal in size and should constrict quickly when exposed to direct light. Assess his extraocular movements. Test motor function by having the patient move his arms and legs through their range of motion. Evaluate sensory function with pinpricks on the patient's skin.
» 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
AMNESIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup of amnesia must include a drug screen, CT scan, or magnetic
resonance imaging (MRI) and often an electroencephalogram (EEG) to rule out
epilepsy. Migraine may be ruled out by a careful history. A neurologist or
psychiatrist will need to be consulted in most cases. If there is fever, a
CBC, chemistry panel, antinuclear antibody (ANA), urinalysis, and blood
cultures should be ordered. A spinal tap may be necessary as well.
» 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
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
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