psychiatric disorders
Medical Assessment of the Patient With Mental Symptoms
Evaluation
Medical assessment by history, physical examination, and often brain imaging and laboratory testing ( Evaluation reference ) is required for patients with New-onset mental symptoms (ie, no prior history of similar symptoms) Qualitatively different or unexpected symptoms (ie, in a patient with a known or stable mental disorder) Mental symptoms that begin at an unexpected age (eg, new-onset psychosis in an older person) The goal of medical assessment is to diagnose underlying and concomitant physical disorders rather than to make a specific psychiatric diagnosis. History of present illnessshould note the nature of symptoms and their onset, particularly whether onset was sudden or gradual and whether symptoms followed any possible precipitants (eg, trauma, illness, starting or stopping of a drug or substance). The clinician should ask whether patients have had previous episodes of similar symptoms, whether a mental disorder has been diagnosed and treated, and, if so, whether patients have stopped taking their drugs. Review of systemsseeks symptoms that suggest possible causes: Vomiting, diarrhea, or both: Volume Depletion , electrolyte disturbance Palpitations: Hyperthyroidism , drug effects including withdrawal Polyuria and polydipsia: Diabetes Mellitus (DM) None Tremors: Parkinson Disease , withdrawal syndromes Difficulty walking or speaking: Multiple Sclerosis (MS) , Parkinson disease, Headache: Central nervous system (CNS) infection, complex migraine, hemorrhage, mass lesion Fever, cough, dysuria, vomiting, or diarrhea: Systemic infection Weight loss: Infection, cancer, Overview of Inflammatory Bowel Disease , hyperthyroidism Paresthesias and weakness: Overview of Vitamins , stroke, demyelinating disease Relapsing and remitting neurologic symptoms: Multiple sclerosis, Overview of Vasculitis None Past medical historyshould identify known physical disorders that can cause mental symptoms (eg, thyroid, liver, or kidney disease; diabetes; HIV or COVID-19 infection). All prescription and over-the-counter drugs should be reviewed, and patients should be queried about any alcohol or illicit substance use (amount and duration). Family history of physical disorders, particularly of thyroid disease and multiple sclerosis, is assessed. Risk factors for infection (eg, unprotected sex, needle sharing, recent hospitalization, residence in a group facility) are noted. Vital signs are reviewed, particularly for fever, tachypnea, hypertension, and tachycardia. Examination of Mental Status is assessed, particularly for signs of confusion or inattention. A full physical examination is done, although the focus is on Signs of infection (eg, meningismus, lung congestion, flank tenderness) The Introduction to the Neurologic Examination (including gait testing and weakness) Funduscopy to detect signs of increased intracranial pressure (eg, papilledema, loss of venous pulsations) Evaluation of the Patient With a Liver Disorder (eg, jaundice, ascites, spider angiomas) should be noted. The skin is carefully inspected for self-inflicted wounds or other evidence of external trauma (eg, bruising). The findings from the history and physical examination help interpret possible causes and guide testing and treatment. Confusion and inattention (reduced clarity of awareness of the environment, suggesting Delirium ), especially if of sudden onset, fluctuating, or both, indicate the presence of a physical disorder. However, the converse is not true (ie, a clear sensorium does not confirm that the cause is a psychiatric disorder). Other findings that suggest a physical cause include Abnormal vital signs (eg, fever, tachycardia, tachypnea) Meningeal signs and symptoms (eg, headache, photophobia, neck rigidity) Abnormalities noted during the neurologic examination, including aphasia Disturbance of gait, balance, or both Incontinence Some findings help suggest a specific cause, especially when symptoms and signs are new or have changed from a long-standing baseline: Dilated pupils (particularly if accompanied by flushed, hot, dry skin): Anticholinergic drug effects Constricted pupils: Opioid drug effects or pontine hemorrhage Rotary or vertical nystagmus: Phencyclidine intoxication Horizontal nystagmus: Often accompanies diphenylhydantoin toxicity Garbled speech or inability to produce speech: A brain lesion (eg, stroke) A preceding history of relapsing-remitting neurologic symptoms, particularly when a variety of nerves appear to be involved: Multiple sclerosis or vasculitis Stocking-glove paresthesias: Possibly thiamin or vitamin B12 deficiency In patients with hallucinations, the type of hallucination is not particularly diagnostic except that command hallucinations or voices commenting on the patient’s behavior probably represent a mental disorder. Symptoms that began shortly after significant trauma or after beginning a new drug may be due to those events. Drug or alcohol use may or may not be the cause of mental symptoms; about 10 to 45% of patients with a mental disorder (varies by diagnosis) also have a Substance Use Disorders (dual diagnosis). A substance use disorder may not be the cause of new mental symptoms; about 10 to 45% of patients with a mental disorder also have a substance use disorder. 1.Toftdahl NG, Nordentoft M, Hjorthøj C: Prevalence of substance use disorders in psychiatric patients: A nationwide Danish population-based study. Social psychiatry and psychiatric epidemiology.Soc Psychiatry Psychiatr Epidemiol51(1):129-140, 2016. doi: 10.1007/s00127-015-1104-4. Testing varies depending on signs and symptoms. If patients with a known mental disorder have an exacerbation of their typical symptoms and they have no medical complaints, a normal sensorium, and a normal physical examination (including vital signs, pulse oximetry, and fingerstick glucose testing), they do not typically require further laboratory testing other than perhaps measurement of therapeutic drug levels. Although new onset mental symptoms or marked change in the nature of symptoms in patients with a known mental disorder may be due to a medical rather than mental disorder, it is unclear how commonly such a disorder is asymptomatic and there is no consensus on routine laboratory testing of medically asymptomatic patients. Some clinicians do one or more of the following to screen for potential disorders: Complete blood count Electrolyte levels (including calcium and magnesium), bloodureanitrogen, and creatinine Erythrocyte sedimentation rate or C-reactive protein Diagnostic tests None Urinalysis Electrolyte and renal function tests may be diagnostic and help inform subsequent drug management (eg, for drugs that require adjustment in patients with renal insufficiency). Patients with signs or symptoms of a medical disorder should have testing appropriate to diagnose that disorder: Head CT: Patients with new-onset mental symptoms or with delirium, headache, history of recent trauma, or focal neurologic findings (eg, weakness of an extremity) Lumbar Puncture (Spinal Tap) : Patients with meningeal signs or with normal head CT findings plus fever, headache, or delirium Thyroid function tests: Patients takinglithium, those with symptoms or signs of thyroid disease, and those>40 years with new-onset mental symptoms (particularly females or patients with a family history of thyroid disease) Chest x-ray: Patients with low oxygen saturation, fever, productive cough, or hemoptysis Blood cultures: Seriously ill patients with fever Laboratory Tests of the Liver and Gallbladder : Patients with symptoms or signs of liver disease, with a history of alcohol or drug use disorder, or with no obtainable history Less often, findings may suggest testing for systemic lupus erythematosus, syphilis, demyelinating disorders, Lyme disease, or vitamin B12 or thiamin deficiency, especially in patients presenting with signs of dementia. Toxicology screening (eg, urine drug screen, blood alcohol level) is done if the patient has a recent history of substance use disorder or physical signs suggesting intoxication or recent drug use (eg, needle marks). 1.Anderson EL, Nordstrom K, Wilson MP, et al: American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults: Part I: Introduction, review and evidence-based guidelines.West J Emerg Med18 (2):235–242, 2017. doi: 10.5811/westjem.2016.10.32258. 