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A cost-effective approach to the diagnostic evaluation of delirium allows the history and physical examination to guide tests. No established algorithm for workup will fit all delirious patients due to the staggering number of potential etiologies, but one step-wise approach is detailed in Table 26-3. If a clear precipitant is identified early, such as an offending medication, then little further workup is required. If, however, no likely etiology is uncovered with initial evaluation, an aggressive search for an underlying cause should be initiated. Table 26-3 Step-Wise Evaluation of a Patient with Delirium Initial evaluation History with special attention to medications (including over-the-counter and. | Chapter 026. Confusion and Delirium Part 6 LABORATORY AND DIAGNOSTIC EVALUATION A cost-effective approach to the diagnostic evaluation of delirium allows the history and physical examination to guide tests. No established algorithm for workup will fit all delirious patients due to the staggering number of potential etiologies but one step-wise approach is detailed in Table 26-3. If a clear precipitant is identified early such as an offending medication then little further workup is required. If however no likely etiology is uncovered with initial evaluation an aggressive search for an underlying cause should be initiated. Table 26-3 Step-Wise Evaluation of a Patient with Delirium Initial evaluation History with special attention to medications including over-the-counter and herbals General physical examination and neurologic examination Complete blood count Electrolyte panel including calcium magnesium phosphorus Liver function tests including albumin Renal function tests First-tier further evaluation guided by initial evaluation Systemic infection screen Urinalysis and culture Chest radiograph Blood cultures Electrocardiogram Arterial blood gas Serum and or urine toxicology screen perform earlier in young persons Brain imaging with MRI with diffusion and gadolinium preferred or CT Suspected CNS infection lumbar puncture following brain imaging Suspected seizure-related etiology electroencephalogram EEG if high suspicion should be performed immediately Second-tier further evaluation Vitamin levels B12 folate thiamine Endocrinologic laboratories thyroid-stimulating hormone TSH and free T4 .
