D. Obtain Medical History, Physical Examination, MSE And Laboratory Tests

OBJECTIVE

Obtain comprehensive patient data in order to reach a working diagnosis.

BACKGROUND

A wide range of medical conditions and treatments may result in abnormal behavior, and many medical disorders may produce or exacerbate psychiatric symptoms in patients with pre-existing mental illness. Multiple studies indicate high rates of medical disease (24 to 50 percent) in patients presenting with psychiatric symptoms (Williams & Shepherd, 2000). Failure to detect and diagnose underlying medical disorders may result in significant and unnecessary morbidity and mortality (Lagomasino et al., 1999). The converse problem is far greater in primary care: patients present with somatic symptoms and have psychiatric disorders that are not properly diagnosed or treated. In one study, 5 of 6 patients with a psychiatric diagnosis had a somatic presentation, and the primary care physician made the diagnosis only half the time, whereas for the 16% with a psychological complaint, the correct diagnosis was made 94% of the time. (Bridges et al., 1985) A standardized approach to medical evaluation including a thorough history, physical examination, laboratory evaluation, and occasionally other ancillary testing prevents the omission of important aspects of the evaluation (Williams & Shepherd, 2000).

RECOMMENDATIONS

1. All patients should have a thorough medical and psychiatric history, with particular attention paid to the following:
   • Baseline functional/mental status
   • Past medical history
   • Medications: to include herbal & over-the-counter (OTC) drugs
   • Past psychiatric history: to include: prior treatment, past hospitalization for depression or suicidality, and substance use disorders
   • Current life stressors
   
   If trauma exposure is recent (<1 month) particular attention should be given to the following:
   • Exposure to/ Environment of trauma
   • Ongoing traumatic event
   • Exposure, perhaps ongoing, to environmental toxin
   • Ongoing perceived threat
2. All patients should have a thorough physical examination. On physical examination, particular attention should be paid to the neurological exam and stigmata of physical/sexual abuse, self-mutilation, or medical illness. Note distress caused by or avoidance of diagnostic tests/examination procedures.
3. All patients, particularly the elderly, should have a Mental Status Examination (MSE) to include assessment of the following:
   • Appearance and behavior
   • Language/speech
   • Thought process (loose associations, ruminations, obsessions) and content (delusions, illusions and hallucinations)
   • Mood (subjective)
   • Affect (to include intensity, range, and appropriateness to situation and ideation)
   • Level of Consciousness (LOC)
   • Cognitive function
4. All patients should have routine laboratory screening tests including TSH, Complete Metabolic Panel, Hepatitis, HIV, and HCG (for females). Also consider CBC, UA, Tox/EtoH panel and other tests, as clinically indicated.
5. Other assessments may be considered (radiology studies, ECG, and EEG), as clinically indicated.
6. All patients should have a narrative summary of psychosocial assessments to include work/school, family, relationships, housing, legal, financial, unit/community involvement, and recreation, as clinically appropriate.

DISCUSSION

Differential diagnosis/co-morbidities associated with PTSD include: dementia, depression, substance abuse/withdrawal, bereavement, psychosis, bipolar disorder, seizure disorder, thyroid disease, neoplasm, somatization disorder (including irritable bowel, headaches, and non-cardiac chest pain), anxiety disorder, toxicosis, rheumatoid-collagen vascular disease, hypoxia, sleep apnea, closed head injury, CHF, and delirium).

Medical History
The medical history may be obtained from the patient, family, friends, or coworkers or from official accounts of a traumatic event:

• Baseline functional/mental status
• Past medical history
• Exposure to/environment of trauma (severity, duration, ongoing risk, and individual vs. community exposure)
• Medications: to include herbal & OTC drugs
• Past psychiatric history to include: prior treatment, past hospitalization for depression or suicidality, and inability to function in usual life roles
• Substance use and misuse can cause and/or exacerbate PTSD. Use of screening tools (such as the CAGE, AUDIT, MAST or DAST can improve detection of substance use disorders (see the VA/DoD Substance Use Guideline, for substance use assessment tools).
• Family history of PTSD or psychiatric disorder
• Sleep/eating patterns
• Current life stressors
• Risk factors suggesting the need for a higher than usual index of suspicion - Certain physiological and psychological conditions or life events may contribute to the development or exacerbation of PTSD symptoms (see Annotation F).

Physical Examination
A brief, screening physical examination may uncover endocrine, cardiac, cerebrovascular, or neurologic disease that may be exacerbating or causing symptoms. Particular attention should be given to a neurologic examination and stigmata of physical/sexual abuse, self-mutilation, or medical illness. Special note should also be made of distress caused by or avoidance of diagnostic tests or examination procedures, since these reactions may be suggestive of prior physical or sexual abuse. Careful attention should also be given to complying with legal mandates for documentation, reporting, and collection of evidence.

Mental Status Examination (MSE)
Particularly in the elderly patient, a full Mental Status Examination (MSE) includes a cognitive screening assessment. The assessment may consist of a standardized instrument such as the Folstein Mini-Mental State Examination (MMSE) (Crum RM, et al., 1993; Cummings JL, 1993; Folstein et al., 1975). If screening is suggestive of cognitive impairment and the patient is not delirious, then a laboratory evaluation to assess for reversible causes of dementia is appropriate. The PTSD assessment should be continued. If delirium is present, consider it an emergency and stabilize the patient before proceeding, then return to the algorithm and continue with PTSD assessment.

During the MSE, Level of Consciousness (LOC) should be assessed to rule out delirium. Abnormal tics or movements should be noted as well as dysarthria, dysprosody, aphasia, agraphia, and alexia which may suggest underlying neurological disease. Sensory illusions may be seen in neurologic syndromes and intoxications (Lagomasino et al., 1999).

Consider seeking further evaluation and consultation from Neuropsychology specialty in cases of suspected cognitive disorders.

Laboratory Evaluation
The history and physical examination findings should be used to direct a conservative laboratory evaluation. There is no test for PTSD, but PTSD is frequently co-morbid with substance use disorders, depression, and high-risk behaviors. Therefore, testing is directed toward detection of associated medical conditions and to rule out contraindications to medical therapy. Appropriate laboratory studies include: TSH, Complete Metabolic Panel, Hepatitis, HIV, and HCG (for females). Also consider CBC, UA, Tox/EtoH Panel and other tests, as clinically indicated.

Other Evaluation

• Diagnostic imaging and neuropsychological testing are not a part of the standard evaluation for PTSD. Proceed with the algorithm while awaiting the completion of the laboratory evaluation.
• MRI/CT of the head may be indicated to rule out mass lesions, intracranial bleeding, hydrocephalus, or subdural hematomas (Lagomasino et. al., 1999).
• ECG may rule out underlying cardiac abnormalities that preclude the use of medications, such as tricyclic antidepressants (Lagomasino et al., 1999).
• Consider EEG or other diagnostic testing, as indicated by history and physical exam.

Psychosocial Assessment

• Past psychiatric illness, treatment, or admission
• Past/ongoing problems with anxiety, impulsivity, mood changes, intense/unstable interpersonal relationships, suicidality, and hallucinations
• Recreational use of drugs/alcohol/tobacco/caffeine
• Social supports (family, friends, homelessness/housing, community, and financial status)
• Losses (bereavement, friend/family member injuries/death, occupation, and moral injury/betrayal)
• Occupational/educational/military history
• Legal issues
• Religious/spiritual history