Diseases » Hallucination » Diagnosis

Diagnosis of Hallucination

Hallucination Diagnosis: Book Excerpts

• Ask the following questions - DELIRIUM
• Ask the Following Questions - HALLUCINATIONS
• Differential Diagnosis - Delirium
• Differential Diagnosis - Hallucinations
• Differential Diagnosis - Delirium
• Differential Diagnosis - Hallucinations
• Approach to the Diagnosis - DELIRIUM
• Approach to Diagnosis - HALLUCINATIONS
• History and physical examination - Halo vision
• History and physical examination - Psychotic behavior
• History - Seizures, complex partial
• History and physical examination - Halo vision
• History and physical examination - Psychotic behavior
• History and physical examination - Seizures, complex partial
• History - Delirium
• Differential Overview - Delirium/Hallucinations
• History - Halo vision
• History - Psychotic behavior
• History - Seizures, complex partial
• History and physical examination - Halo vision
• History and physical examination - Psychotic behavior
• History and physical examination - Seizures, complex partial
• Approach to the Diagnosis - DELIRIUM
• Approach to the Diagnosis - HALLUCINATIONS

Diagnosis of Hallucination: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Hallucination:

• Delirium common amongst patients undergoing stem cell transplant
• Different types of sleep disorders plague many millions of Americans
• More news »

Diagnostic Tests for Hallucination: Online Medical Books

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

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

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

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.

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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

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

First, ask the patient how long he has been seeing halos around lights and when he usually sees them. The patient with glaucoma usually sees halos in the morning, when IOP is most elevated. Ask the patient if light bothers his eyes. Does he have eye pain? If so, have him describe it. Remember that halos associated with excruciating eye pain or a severe headache may point to acute angle-closure glaucoma, an ocular emergency. Note a history of glaucoma or cataracts.

Next, examine the patient’s eyes, noting conjunctival injection, excessive tearing, and lens changes. Examine pupil size, shape, and response to light. Then test visual acuity by performing an ophthalmoscopic examination.

» READ BOOK EXCERPT ONLINE »

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

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

Because the patient’s behavior can
make it difficult — or potentially dangerous — to obtain pertinent information, conduct the interview in a calm, safe, and well-lit room. Provide enough personal space to avoid threatening or agitating the patient. Ask him to describe his problem and circumstances that may have precipitated it. Obtain a drug history, noting especially the use of an antipsychotic, and explore his use of alcohol and other drugs, such as cocaine, indicating duration of use and amount. Ask about recent illnesses or accidents.

As the patient talks, watch for cognitive, linguistic, or perceptual abnormalities such as delusions. Do thoughts and actions seem to match? Look for unusual gestures, posture, gait, tone of voice, and mannerisms. Does the patient appear to be responding to stimuli? For example, is he looking around the room?

Interview the patient’s family. Which family members does he seem closest to? How does the family describe the patient’s relationships, communication patterns, and role? Has a family member ever been hospitalized for psychiatric or emotional illness? Ask about the patient’s compliance with his drug regimen.

Finally, evaluate the patient’s environment, educational and employment history, and socioeconomic status. Are community services available? How does the patient spend his leisure time? Does he have friends? Has he ever had a close emotional relationship?

» READ BOOK EXCERPT ONLINE »

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

Seizures, complex partial: History
(Handbook of Signs & Symptoms (Third Edition))

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

» READ BOOK EXCERPT ONLINE »

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

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

First, ask the patient how long he has been seeing halos around lights and when he usually sees them. Patients with glaucoma usually see halos in the morning, when IOP is most elevated. Ask the patient if light bothers his eyes. Does he have eye pain? If so, have him describe it. Remember that halos associated with excruciating eye pain or a severe headache may point to acute angle-closure glaucoma, an ocular emergency. Note a history of glaucoma or cataracts.

Next, examine the patient’s eyes, noting conjunctival injection, excessive tearing, and lens changes. Examine pupil size, shape, and response to light. Then test visual acuity by performing an ophthalmoscopic examination.

» READ BOOK EXCERPT ONLINE »

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

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

Because the patient’s behavior can make it difficult—or potentially dangerous—to obtain pertinent information, conduct the interview in a calm, safe, and well-lit room. Provide enough personal space to avoid threatening or agitating the patient. Ask him to describe his problem and any circumstances that may have precipitated it. Obtain a drug history, noting especially use of an antipsychotic, and explore his use of alcohol and other drugs such as cocaine, indicating duration of use and amount. Ask about any recent illnesses or accidents.

As the patient talks, watch for cognitive, linguistic, or perceptual abnormalities such as delusions. Do thoughts and actions seem to match? Look for unusual gestures, posture, gait, tone of voice, and mannerisms. Does the patient appear to be responding to stimuli? For example, is he looking around the room?

Interview the patient’s family. Which family members does he seem closest to? How does the family describe the patient’s relationships, communication patterns, and role? Has any family member ever been hospitalized for psychiatric or emotional illness? Ask about the patient’s compliance with his drug regimen.

Finally, evaluate the patient’s environment, educational and employment history, and socioeconomic status. Are community services available? How does the patient spend his leisure time? Does he have friends? Has he ever had a close emotional relationship?

» READ BOOK EXCERPT ONLINE »

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

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

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

» READ BOOK EXCERPT ONLINE »

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

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

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

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

First, ask the patient how long he has been seeing halos around lights and when he usually sees them. Patients with glaucoma usually see halos in the morning, when IOP is most elevated. Ask the patient if light bothers his eyes. Does he have eye pain? If so, have him describe it. Remember that halos associated with excruciating eye pain or a severe headache may point to acute angle-closure glaucoma, an ocular emergency. Note a history of glaucoma or cataracts.

» READ BOOK EXCERPT ONLINE »

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

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

Because the patient’s behavior can make it difficult — or potentially dangerous — to obtain pertinent information, conduct the interview in a calm, safe, and well-lit room. Provide enough personal space to avoid threatening or agitating the patient. Ask him to describe his problem and any circumstances that may have precipitated it. Obtain a drug history, noting especially use of an antipsychotic, and explore his use of alcohol and other drugs such as cocaine, indicating duration of use and amount. Ask about recent illnesses or accidents.

Interview the patient’s family. Which family member does he seem closest to? How does the family describe the patient’s relationships, communication patterns, and role? Has any family member ever been hospitalized for psychiatric or emotional illness? Ask about the patient’s compliance with his drug regimen.

Finally, evaluate the patient’s environment, educational and employment history, and socioeconomic status. Are community services available? How does the patient spend his leisure time? Does he have friends? Has he ever had a close emotional relationship?

» READ BOOK EXCERPT ONLINE »

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

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

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

» READ BOOK EXCERPT ONLINE »

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

Halo vision: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

First, ask the patient how long he has been seeing halos around lights and when he usually sees them. The patient with glaucoma usually sees halos in the morning, when IOP is most elevated. Ask the patient if light bothers his eyes. Does he have eye pain? If so, have him describe it. Remember that halos associated with excruciating eye pain or a severe headache may point to acute angle-closure glaucoma, an ocular emergency. Note a history of glaucoma or cataracts.

Next, examine the patient's eyes, noting conjunctival injection, excessive tearing, and lens changes. Examine pupil size, shape, and response to light. Then test visual acuity by performing an ophthalmoscopic examination.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Psychotic behavior: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Because the patient's behavior can make it difficult—or potentially dangerous—to obtain pertinent information, conduct the interview in a calm, safe, and well-lit room. Provide enough personal space to avoid threatening or agitating the patient. Ask him to describe his problem and circumstances that may have precipitated it. Obtain a drug history, noting especially the use of an antipsychotic, and explore his use of alcohol and other drugs, such as cocaine, indicating duration of use and amount and when it was last taken. Ask about recent illnesses or accidents.

As the patient talks, watch for cognitive, linguistic, or perceptual abnormalities such as delusions. Do thoughts and actions seem to match? Look for unusual gestures, posture, gait, tone of voice, and mannerisms. Does the patient appear to be responding to stimuli? For example, is he looking around the room?

Interview the patient's family. Which family members does he seem closest to? How does the family describe the patient's relationships, communication patterns, and role? Has a family member ever been hospitalized for psychiatric or emotional illness? Ask about the patient's compliance with his drug regimen.

Finally, evaluate the patient's environment, educational and employment history, and socioeconomic status. Are community services available? How does the patient spend his leisure time? Does he have friends? Has he ever had a close emotional relationship?

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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

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

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Source: Nursing: Interpreting 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. 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.

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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.

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Source: Differential Diagnosis in Primary Care, 2007

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