What is a recommended fill-in-the-blank template for the History of Present Illness (HPI) for a patient presenting with altered mental status?

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Fill-in-the-Blank Template for History of Present Illness (HPI) in Altered Mental Status

The most effective HPI for a patient with altered mental status should follow a structured, comprehensive approach that addresses all key domains of cognitive and behavioral symptoms and their impact on daily function.

Chief Complaint

Patient is a [age]-year-old [gender] presenting with [duration] of altered mental status characterized by [specific symptoms: confusion/disorientation/lethargy/agitation/hallucinations/etc.].

Characterization of Symptoms

  • Onset and progression: Symptoms began [abruptly/gradually] approximately [timeframe] ago and have [improved/worsened/fluctuated] since onset.
  • Specific cognitive changes: Patient has demonstrated [memory problems/disorientation to time, place, person/difficulty with attention/language difficulties/impaired reasoning].
  • Behavioral changes: [Agitation/lethargy/inappropriate behavior/hallucinations/delusions/sleep-wake cycle disturbances].
  • Level of consciousness: Patient has been [alert/drowsy/difficult to arouse/unresponsive].
  • Fluctuation pattern: Symptoms [remain constant/fluctuate throughout the day/worse at night/"sundowning"].

Impact on Daily Function

  • Activities of daily living (ADLs): Patient [is/is not] able to [dress/bathe/toilet/feed] independently.
  • Instrumental activities (IADLs): Patient [is/is not] able to [manage medications/handle finances/prepare meals/use transportation].
  • Safety concerns: [Falls/wandering/unsafe use of appliances/inability to recognize dangerous situations].

Associated Symptoms

  • Neurological: [Headache/focal weakness/sensory changes/visual disturbances/seizure activity].
  • Systemic: [Fever/chills/pain/shortness of breath/urinary symptoms/recent infections].
  • Mood/psychiatric: [Depression/anxiety/paranoia/hallucinations/suicidal ideation].

Potential Triggers or Precipitating Factors 1

  • Recent medication changes: [New medications/dose adjustments/missed doses/over-the-counter medications].
  • Substance use: [Alcohol/recreational drugs/recent changes in use patterns/withdrawal].
  • Recent procedures/hospitalizations: [Surgery/anesthesia/recent hospitalization/procedures].
  • Environmental changes: [Recent relocation/unfamiliar surroundings/hospitalization].
  • Metabolic factors: [Recent dietary changes/dehydration/electrolyte abnormalities].

Relevant Medical History

  • Prior cognitive issues: [Baseline cognitive function/prior episodes of altered mental status/dementia diagnosis].
  • Neurological conditions: [Stroke/seizures/head trauma/neurodegenerative disorders].
  • Systemic conditions: [Diabetes/hypertension/renal disease/liver disease/cardiac disease/pulmonary disease].
  • Psychiatric history: [Depression/anxiety/psychosis/substance use disorders].

Collateral Information 1

  • Source of information: [Relationship to patient/reliability/frequency of contact].
  • Baseline function: Patient's baseline cognitive status was [fully independent/mild impairment/moderate impairment].
  • Timeline of changes: [Informant's description of onset and progression of symptoms].
  • Recent life events: [Stressors/changes in living situation/loss of loved ones].

Risk Factors for Cognitive Decline 1

  • Age-related: [Age/family history of dementia].
  • Vascular risk factors: [Hypertension/diabetes/hyperlipidemia/smoking/obesity].
  • Other modifiable factors: [Sleep disorders/hearing loss/social isolation/physical inactivity].

Medication Review

  • Current medications: [Complete list with doses and schedules].
  • High-risk medications: [Anticholinergics/benzodiazepines/opioids/sedatives/hypnotics].
  • Adherence: [Patient's typical adherence pattern/recent changes].

Vital Signs and Physical Findings

  • Vital signs: [Temperature/blood pressure/heart rate/respiratory rate/oxygen saturation].
  • General appearance: [Level of distress/hygiene/nutritional status].
  • Neurological findings: [Mental status exam findings/focal deficits/abnormal movements].

Assessment Tools Used 1, 2

  • Cognitive screening: [Results of tools used: CAM/Richmond Agitation Sedation Scale/Glasgow Coma Scale].
  • Delirium assessment: [Results of CAM/B-CAM assessment].

Initial Impression

Based on the above history and examination findings, the patient's altered mental status appears most consistent with [delirium/dementia/psychiatric condition/metabolic encephalopathy/intoxication/withdrawal/structural brain disease/infection].

Plan for Further Evaluation

  • Laboratory studies: [CBC/BMP/LFTs/UA/toxicology/cultures/other specific tests].
  • Imaging: [Head CT/Brain MRI/Chest X-ray].
  • Other studies: [EEG/LP/other specialized testing].

Important Clinical Considerations:

  • Always obtain information from both the patient AND a reliable informant 1
  • Document fluctuations in mental status, as this is a cardinal feature of delirium 1
  • Carefully review all medications, as they are common precipitants of altered mental status 2
  • Remember that delirium is a medical emergency with mortality rates twice as high when missed 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Hallucinations in Medical Conditions

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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