iiie~oioui~?aiofErnergencyn/lediwn~
Vol 5 pp 367-373
1987

PSYCHIATRIC

PrintedI” the USA ??CopyrIght 1 1987 Peqamon JONIF Ltd

PRESENTATION

OF MEDICAL ILLNESS

Daniel W. Spaite, MD,* and Roger A. Smith, MDt
‘AssIstant Professor, Sectlon of Emergency Medlclne, Department of Surgery. University of Arizona.
College of Medwne, Tucson, tunlversity of Arizona College of Medlclne, Tucson
Repnni address Daniel W Spaite. MD Section of Emergency Medicine, University of Arizona
Health Sciences Center. Tucson, AZ 85724

0 Abstract -A 37-year-old woman was seen
in the emergency department for symptoms of
depression. A careful mental status examination resulted in the discovery of an organic basis for the “psychiatric” presentation. As with
any patient demonstrating behavioral abnormalities, this case illustrates the importance of
an adequate history, physical, and mental status evaluation in ruling out organic etiology
prior to labeling a patient’s complaints as functional. Medical illnesses that can present as apparent psychiatric disease and the clinical clues
that lead to the diagnosis of such cases are
discussed.

Case Report
A 37-year-old woman arrived at the emergency department
with a l-week history
of depression.
Neighbors
described
the
patient as having become very quiet over
the past several days with noticeable social
withdrawal.
Some of her fellow workers
became concerned
when she failed to
come to work for a week. They went to
her home and found her to be alert but
withdrawn,
so they brought
her to the
emergency
department.
Upon questioning, the patient reported diminished appetite and some weight loss, but denied lethargy, early morning awakening,
or other
vegetative symptoms
of depression.
She
had not contemplated
suicide and had no
prior psychiatric
history.
When asked
about missing work, the patient stated
that she thought someone else was work-

II Keywords - organic brain syndrome;
functional illness; disorientation; mental
status exam; memory loss

Introduction
Frequently,
the emergency
physician encounters patients with behavioral
abnormalities. Such patients may be confused,
fearful, combative, psychotic, uncooperative, or manifest
bizarre and inappropriate behavior. In this situation,
it is incumbent upon the emergency physician to
determine
if the patient’s abnormal
behavior is a manifestation
of organic illness. This is important
since many of the
symptoms that lead to psychiatric referral
may actually be manifestations
of remedial organic pathology.

RECEIVED: 22 December

A large number of diseases may result
in psychiatric symptoms and the incidence
of medical illness in psychiatric patients is
high.lmh Accurate identification
of those
patients
with psychiatric
complaints
caused by organic illness requires careful
attention to certain details of the history,
physical, and mental status examinations.
The following
case illustrates
such a
patient.

1986; ACCEPTED: 23 February
367

1987 0736-4679/87

$3.00 + .OO

368

ing for her. During the previous week she
had spent her time at home watching television and exercising. There was no history of headaches, visual changes, diplopia,
hallucinations,
nausea,
vomiting,
weakness, paraesthesias,
or disturbances
of
gait or speech. Her medical history was
unremarkable
and she was currently taking no medications.
Family history was
significant
for a younger
brother
with
schizophrenia.
She denied drug or excessive alcohol use and reported being gay.
Recent stresses included a break up with
her girlfriend,
and an abortion
one year
previously.
The patient
had completed
high school without difficulty, and her job
entailed cleaning glassware in a biochemistry lab.
Physical examination
revealed a cooperative, alert, well-appearing
woman with
good eye contact but a noticeably flat affect. Vital signs were: temperature,
98.6”F; pulse rate, 80 beats per minute;
blood pressure, 106/74 mm Hg; respirations, 16/min. Head, eyes, ears, throat exams were within normal limits including
round, equal, reactive pupils and a normal funduscopic
examination.
The neck
was supple without thyromegaly,
jugular
venous distension,
or carotid bruits. Auscultation of the chest revealed clear and
equal breath sounds bilaterally. Examination of the heart revealed a normal S, and
S,, with a regular rate and rhythm. There
was a II/VI early to midsystolic murmur
heard best at the left lower sternal border
radiating to the apex. There were no gallops. The abdomen was soft and nontender with normal bowel sounds. No hepatosplenomegaly
or palpable
mass was
present. There was no clubbing, cyanosis,
or peripheral edema. Neurological
examination revealed the patient to be alert and
oriented to person, place, and time with
good motor strength bilaterally
and no
sensory deficits. Reflexes were symmetrical bilaterally
with cranial nerves II-XII
intact. Her toes were down going bilaterally. Rhomberg test was negative, and cerebellar function
was normal,
as was her

Daniel W. Spalte and Roger A. Smith

gait. The patient exhibited poor recent
memory and was only able to recall two of
three objects
immediately
and one of
three objects at five minutes.
Although
she was able to recall her birth date, there
was a significant period of delay to “think
about it.” She was unable to interpret
proverbs or do serial 7s or 3s. General
knowledge was intact.
Initial laboratory
values were: hemoglobin
13.7 g/dL;
hematocrit
37.3%;
WBC 7,5OO/pL with 74% polys,
1%
bands, 19% lymphocytes,
5% monocytes,
and 1% eosinophils.
Serum electrolytes,
BUN, and creatinine were normal. Additional laboratory tests revealed serum calcium, 9.6 mg/dL; magnesium,
2.1 mEq/
L; phosphorus,
3.6 mg/dL;
and blood
glucose,
86 mg/dL.
Although
the patient’s sensorium was intact, computed tomography (CT) scan of the head was obtained
at this time because
of the
impairment
of memory
and cognitive
function.
This revealed a lucency in the
region of the left caudate nucleus most
consistent
with infarction
or neoplasm
(Figure 1). A chest X-ray study was obtained and was normal.
The neurology
service was consulted and the patient was
admitted for further evaluation.
One day
after admission
the patient underwent
a
magnetic resonance imaging study that revealed lesions in the head of the left
caudate, corona radiata, and globus pallidus, with minimal mass effect noted. It
was felt that although
ischemic injury
could not be entirely ruled out, the findings were most consistent
with that of
neoplasm.
Lumbar
puncture
was performed, revealing total serum protein, 32
g/dL; blood glucose 115 mg/dL; WBC 6/
pL, with 98% monocytes and 2% polys.
Gram’s stain, culture and CSF cytology
were negative.
Thyroid-stimulating
hormone, T,, T,, and T,I were normal and
Venereal Disease Research Laboratory test
result was negative. An EEG was also performed and was normal.
Neurosurgery
was consulted and agreed that tumor was
most likely but that cerebral infarction

Psychiatric Presentation

Figure 1. CT scan obtained at the time of the
patient’s initial presentation. Note contrast-enhanced lucency in the region of the left caudate
nucleus with impingement into the left lateral
ventricle.

was still a significant
possibility.
It was
thus decided to follow the patient closely
as an outpatient
and repeat the CT scan 1
month later with a possible needle biopsy
at that time. The patient remained stable
with a slight improvement
in memory and
cognitive function during this l-month interval. The CT was repeated as planned
but this time was diagnostic of a segmental infarct (Figure 2). She was admitted for
a workup to determine the cause. Cardiology consultation
was obtained
and an
echocardiogram
revealed mitral valve prolapse with significant
degeneration
of the
valve leaflets. Although no clot was identified, it was felt that an embolus from the
abnormal
valve was the cause of the cerebral infarct and the patient was therefore
started on anticoagulation
therapy. Several months later, the patient remains on
warfarin (Coumadin)
and is doing well.
Her deficits of memory
and cognitive
function have completely resolved.

:369

Figure 2. CT scan obtained 1 month after the
initial scan. Evidence of an old infarction within
the head of the left caudate nucleus is seen.
Some increased prominence of the left lateral
ventricle as well as a small area of encephalomalacia are also visualized.

Discussion
The emergency
physician
is frequently
faced with the formidable
task of determining whether a patient’s abnormal
behavior is caused by organic brain disease
or is entirely functional
in nature. Often
the tendency is to make this determination
early on in the evaluation
and label the
patient as “organic” or “psychiatric”
with
very little historical
or clinical information.‘-’ Unfortunately,
the tendency to label patients with overtly psychiatric
presentations
as functional
can often lead
physicians to ignore important
aspects of
the history, physical, and mental status examinations.
Thus, patients
with important pathological
processes may undergo
significant deterioration
before the underlying organic cause becomes obvious. In

370

some cases, even if this is a relatively brief
delay, significant morbidity or even death
may result.
Despite the common tendency to separate patients into either organic or psychiatric categories,
it is clear that the two
coincide in a large percentage of cases.‘,j
As many as 42% of those who present as
outpatients
with psychiatric
complaints
have been found to have significant
concomitant
medical illness.?~“~“)~” In up to
20% of these patients a physical disorder
was considered to be the primary cause of
the “psychiatric”
presentation.
Patients
who are hospitalized on psychiatric wards
have an even higher incidence of medical
illness with estimates ranging from 33%
to 80%.3.1Z-lq One of the most striking
findings found among these patients has
been the high incidence of illness that was
previously
unknown
to the patients
or
their physician.3,r0
Many potentially
life-threatening
illnesses may have a behavioral disturbance
as their most obvious and striking symptoms. Table 1 is a summary
of medical
disorders that may present clinically as a
primarily psychiatric problem.~~h~15~Z7
The emergency physician must become
adept at identifying those patients who, in
fact, have an underlying
medical illness.
Although
there is no perfect screening
test, there are several fundamental
pieces
of information
that can generally be obtained from the history, physical,
and
mental status examination
that will aid in
recognizing a large percentage of these patients (Table 2). Although all patients with
behavioral disturbances
will have “altered
mental status” (depression,
suicidal ideations, inappropriate
behavior, hallucinations, etc), there are certain key aspects of
the mental status examination
that are the
most sensitive indicators of organicity. Alteration
or fluctuation
of orientation
should never be considered
“functional”
until a careful
evaluation
for organic
causes has been undertaken.
Memory, including immediate recall, must always be
tested and any significant
abnormalities

Daniel W. Spaite and Roger A. Smith

Table 1. Medical Diseases That Can Present
With Primarily Psychiatric
Complaints3-6~‘5- ’
Cardiovascular
Congestive heart failure
Arrhythmia
Hypertensive crisis
Metabolic/Endocrine
Hypoxia
Hypoglycemia
Hyperglycemia
Diabetic ketoacidosis
Hyponatremia
Hypercalcemia
Uremia
Hyperthyroidism
Hypothyroidism
Hypoparathyroidism
Hyperparathyroidism
Incipient delerium tremens
Addison’s disease
Wilson’s disease
Drug/Toxic
Ethanol
Digoxin
Propranolol
Methyldopa
Procainamide
Reserpine
lsoniazid
Sulfonamides
Diphenylhydantoin
Levodopa
Anticholinergics
Antihistamines
Lithium
Cimetidine
Amphetamines
Barbiturates
Benzoadiazepines
Phenothiazines
Tricyclic antidepressants
Steroids
Aminophylline
Oral hypoglycemics
Insulin
Salicylates
Bromides
Carbon monoxide
Heavy metals (mercury, manganese,
Infectious
Encephalitis
Tuberculosis
Brain abscess
Sepsis of many causes
Neurosyphilis
Meningitis
Collagen Vascular
Systemic lupus erythematosus
Rheumatoid arthritis
Neoplastic
Meningiomas (particularly frontal)
Brain metastases
Bronchogenic carcinoma

lead)

(contmued)

Psychratrrc

Presentation

Table 1. Continued
Hepatoma
Pancreatic carcinoma
Trauma
Postconcussive syndrome
Subdural hematoma
Pulmonary
Pulmonary embolus
Chronic obstructive pulmonary disease
Gastrointestinal
Hepatic encephalopathy
Pancreatitis
Ulcerative colitis
Neurological
Alzheimer’s disease
Multi-infarct dementia
Huntington’s disease
Seizures (especially temporal lobe)
Normal pressure hydrocephalus
Multiple sclerosis
Other
Anemia
Folic acid deficiency
Sarcoidosis
Scabies
Pinworm (in young children)
Dehydration

should lead to an intense search for an
underlying
medical
illness.
Cognitive
function should be tested and any abnormalities evaluated
with reference to the
patient’s educational
and cultural background.
Patients who exhibit slurred or
slowed speech must be taken seriously,
particularly
if it is a new finding.
The
presence of visual, olfactory,
or tactile
hallucinations
is also associated with an
increased incidence of organic etiology. In
a study by Hall and associates,’ 20% of
patients with behavioral manifestations
of
medical illness experienced visual hallucinations
compared
with only 0.5% of
those psychiatric patients who had no underlying medical cause.
The case presented in this report shows
the importance
of a careful mental status
examination
in patients
presenting
with
psychiatric
complaints.
The patient was
alert and oriented to person, place, and
time and her neurologic
examination
revealed no focal findings. However, the impairment of memory and cognitive function led the emergency physician to search
for an organic basis for the patient’s “psy-

371

chiatric” problem. A recent study by Zun
and Gold’” found that the mental status
exam performed by emergency physicians
is quite variable. In their series, only onethird routinely included testing of memory and immediate
recall and even fewer
tested cognitive function on a routine basis. In the case of this patient, had the
finding of “oriented
times three” been
considered
equivalent
to “mental status:
intact,” the intracranial
pathology
might
have been missed altogether. Clearly, the
examination
of mental status in the emergency department
must go beyond simply
testing orientation.
When clues in the history, physical, or
mental status examinations
point to the
possibility
of an organic
cause,
this
should be pursued. Serum glucose, electrolytes, creatinine,
CBC, and urinalysis
may lead to a specific diagnosis. In certain
circumstances,
laboratory
evaluations
such as toxicologic screens, arterial blood
gases, lumbar puncture,
calcium, magnesium, serum ammonia,
and other tests
might be indicated.
The use of the CT
scan in the psychiatric population
in general, as well as in patients presenting with
psychiatric
complaints
to the emergency
department,
has received significant
attention in the literature and remains controversial.5,1’,‘%33 Currently there is no universally accepted criteria for the use of the
CT scan in this setting. However, as with
other tests, it should be used when the
possible benefits outweigh the cost and
risks involved in the procedure. Obviously, each case must be evaluated individually, but if the clinical presentation
points
toward the possibility of the presence of a
structural
brain lesion, a scan should be
obtained.
Certainly
patients with an altered level of consciousness
or focal neurologic
findings
should
be scanned
emergently unless other historical or laboratory data argue convincingly
against the
presence of a brain lesion. Other relative
indications
include onset of major psychiatric illness after the age of 40, patients
with a history of trauma, or new onset of

Daniel W. Spatte and Roger A. Smith

372

Table 2. Clinical Clues to the Presence of an
Organic Cause of Psychiatric Presentation
History
Onset of major psychiatric illness after 40 years of age
Significant medical illness (endocrine, cardiovascular, neurologic, etc)
No previous psychiatric history
History of drug or alcohol abuse
Medications with potential for side effects resulting in behavioral disturbance
History of poor response to “psychiatric” treatment
Physical Exam
Abnormal vital signs
Depressed or fluctuating level of consciousness
Cyanosis
Evidence of trauma
Incontinence (new onset)
Focal neurologic signs
Ataxia
Tremor
Dysarthria
Mental Status Exam
Fluctuating or altered orientation
Impaired memory
Impaired cognitive function
Slowed speech or delayed verbal response
Visual, olfactory, or tactile hallucinations

incontinence (Table 2). Patients with unexplained impairment of orientation, memory, or cognition, and in whom efforts to
determine the underlying cause by laboratory examination have been unsuccessful,
should receive a CT scan as these may be
the earliest signs of a structural brain lesion (as in the case presented here).
Summary
The possibility of an organic disturbance
must be included in the differential diag-

nosis of any patient with a behavioral disorder. Psychiatric symptoms are frequently the first manifestations of structural
CNS pathology and other medical illnesses. Only after the high-risk signs and
symptoms have been carefully pursued
and the presence of an underlying medical
condition ruled out, should the term
“medically cleared for psychiatric evaluation” be used.
Acknowledgemenf-The
authors
wish to thank
Glenda King for her assistance in the preparation
of
this manuscript.

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