Medical Assessment of the Patient With Mental Symptoms

History of present illness should 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 systems seeks symptoms that suggest possible causes:

Past medical history should 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. Mental status 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 liver disease Evaluation of the Patient With a Liver Disorder History and physical examination often suggest a cause of potential liver disorders and narrow the scope of testing for hepatic and biliary disorders. Various symptoms may develop, but few are... read more (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 Delirium Delirium is an acute, transient, usually reversible, fluctuating disturbance in attention, cognition, and consciousness level. Causes include almost any disorder or drug. Diagnosis is clinical... read more ), 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

Some findings help suggest a specific cause, especially when symptoms and signs are new or have changed from a long-standing baseline:

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 disorder Substance Use Disorders Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance... read more (dual diagnosis).

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:

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:

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).