Medical Workup for Patients with Delusions

Initial Clinical Assessment

The American College of Radiology recommends a comprehensive medical workup for patients presenting with delusions, including thorough clinical assessment, targeted laboratory testing, selective neuroimaging, and specialized psychiatric evaluation to distinguish between primary psychiatric disorders and secondary causes of delusions 1, 2, 3
A mental status examination should be performed to assess appearance, behavior, thought process, thought content, mood, affect, insight, and judgment in patients with delusions 4
The Confusion Assessment Method (CAM) or its variants can be used to evaluate for cardinal features of delirium in patients with delusions 1, 3
Primary psychosis, such as schizophrenia, bipolar disorder, schizoaffective disorder, and depression with psychotic features, should be distinguished from secondary causes related to medical conditions in patients with delusions 1, 5
Focal neurological deficits should be assessed, as they may indicate underlying intracranial pathology in patients with delusions 2

A complete blood count can help evaluate for infection or hematologic abnormalities in patients with delusions 3, 6
A comprehensive metabolic panel can assess electrolyte imbalances, renal and liver function in patients with delusions 3, 6
Urinalysis can screen for urinary tract infections, a common precipitating factor for delirium in patients with delusions 1, 3
Blood glucose measurement can rule out hypo/hyperglycemia in patients with delusions 3, 6
Thyroid function tests can evaluate for thyroid disorders in patients with delusions 3
Medication levels should be checked when appropriate, especially for patients on psychotropic medications with delusions 6
A toxicology screen can assess for substance intoxication or withdrawal in patients with delusions 1, 5

The American College of Radiology recommends that brain CT scans be performed selectively rather than routinely, guided by specific clinical features in patients with delusions 2, 3
Indications for neuroimaging include focal neurological deficits, history of recent head trauma, new-onset seizures, signs of increased intracranial pressure, and unexplained altered mental status despite initial workup in patients with delusions 2, 3
MRI may be preferred when available, though challenges exist with patients who may be combative or unable to follow commands 2
Chest radiography can evaluate for pneumonia or other pulmonary processes that may contribute to delirium in patients with delusions 2, 6

An electrocardiogram can assess for myocardial ischemia or arrhythmias in patients with delusions 2, 3
Electroencephalography (EEG) can be used when seizure activity is suspected in patients with delusions 2
Lumbar puncture can assess for central nervous system infection when clinically indicated in patients with delusions 2

Failing to recognize hypoactive delirium, which is commonly missed in clinical settings, can lead to delayed diagnosis and treatment in patients with delusions 3, 6
Attributing symptoms to dementia without investigating for acute causes can lead to missed diagnosis and inappropriate treatment in patients with delusions 3
Inadequate screening can lead to missed diagnosis in emergency settings in patients with delusions 3
Mistaking delirium for primary psychiatric disorders can lead to inappropriate treatment and delayed diagnosis in patients with delusions 6
Overlooking medical conditions that may present with psychotic symptoms, including endocrine disorders, autoimmune diseases, neoplasms, neurologic disorders, infections, genetic/metabolic disorders, nutritional deficiencies, and drug-related issues, can lead to delayed diagnosis and treatment in patients with delusions 1, 5

Treatment should target the underlying cause when identified in patients with delusions 1, 5
For primary psychosis, consider pharmacologic management with antipsychotic medications, psychological therapy, and psychosocial interventions 1
For delirium, implement non-pharmacological approaches including reorientation, maintaining normal sleep-wake cycles, and creating a calm environment 6
Pharmacological interventions for delirium should be limited to patients with distressing symptoms or safety concerns 6