Both history and physical findings are necessary to confirm the diagnosis of delirium. The history is needed to confirm the acuity of the change in behavior and reveal the fluctuating confusion consistent with the delirium. The history from caregivers, spouse, or other family members is the primary mechanism for diagnosing delirium. 3 General physical examination is directed at discovering an underlying process such as an infection. Ancillary testing should include basic chemistries, urinalysis, and blood count, and a chest radiograph. Cranial CT and CSF analysis should be considered on an individual basis. The physician must decide if an identified acute illness is sufficient to cause the delirium or if further diagnostic workup is necessary; this is often not an easy decision. In absence of a definitive explanation, CT and CSF analysis are advised but, depending on the acuity of onset, could be deferred as part of a continuing inpatient workup.
One key feature of examination is the mental status examination. The standard mental status evaluation may be divided into six categories: appearance, behavior, and attitude; disorders of thought; disorders of perception; mood and affect; insight and judgement; and sensorium and intelligence ( Tabj.® 221z2). The "standard" mental status examination is useful particularly to determine potential for a psychiatric condition. The emergency physician is unlikely to have time to perform the same detailed evaluation as a general psychiatrist or neurologist. However, the assessment of mood, affect, dress, situational behavior, and, in particular, speech content and process are key aspects in uncovering a psychiatric condition. While the standard mental status examination may not be as useful in the ED for assessment of cognitive function as the other approaches that are discussed later, assessment of orientation and level of consciousness are still helpful as initial screens, as these are usually unimpaired in pure psychiatric conditions, except possibly when the condition is severe. Thus, impairments in cognitive function uncovered with this examination suggest the presence of delirium or other organic mental disorder, and further evaluation along these lines is warranted.
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