Documentation of Delusional and Bizarre Symptoms in Review of Systems
Yes, symptoms that appear delusional and bizarre in nature should absolutely be documented in the review of systems, as these symptoms are critical diagnostic indicators that help differentiate between medical emergencies (delirium), primary psychiatric disorders (psychosis), and underlying medical conditions. 1
Why These Symptoms Must Be Documented
Diagnostic Necessity
Delusions and hallucinations are cardinal features of altered mental status presentations and serve as essential data points for distinguishing between life-threatening conditions and primary psychiatric disorders. 1
The American College of Radiology explicitly includes hallucinations, delusions, and psychosis as part of the comprehensive symptom assessment for altered mental status, alongside confusion, disorientation, lethargy, and agitation. 1
These symptoms help determine whether consciousness is intact or impaired, which is the single most critical distinction in altered mental status evaluation—intact consciousness suggests primary psychosis, while impaired consciousness indicates delirium (a medical emergency with doubled mortality if missed). 2, 3
Clinical Decision-Making Impact
Visual hallucinations are the strongest indicator of an underlying medical cause rather than primary psychiatric disorder, making documentation of the specific type of perceptual disturbance clinically essential. 2
Up to 46% of patients presenting with psychiatric symptoms have an underlying medical disease that is causative or exacerbating, making thorough documentation of bizarre symptoms critical for identifying these medical etiologies. 2
The presence or absence of delusions helps differentiate delirium (where delusions may occur but are not required for diagnosis) from primary psychotic disorders (where delusions are a cardinal feature). 1
How to Document These Symptoms
Specific Elements to Record
Document the exact nature of the perceptual disturbance: hallucinations (perceptions without external stimuli) versus delusions (false beliefs refuted by objective evidence). 1
Record whether the patient's level of consciousness and attention are intact or impaired, as this determines whether the symptoms represent delirium or psychosis. 1
Note any fluctuation in symptoms throughout the day, as fluctuating course with lucid intervals is characteristic of delirium rather than primary psychosis. 3
Document associated symptoms including disorganized speech, abnormal motor behavior, sleep disturbances, and emotional disturbances (fear, anxiety, anger). 1
Standard Practice Across Specialties
HIV medicine guidelines explicitly recommend including changes in neurological function or mental status in the review of systems, demonstrating that psychiatric symptoms are standard components of comprehensive medical assessment. 1
Critical care guidelines require systematic assessment of delirium features including hallucinations and delusions as part of routine ICU patient evaluation. 1
Rheumatology guidelines for systemic lupus erythematosus specifically mandate documentation of delusions and hallucinations to identify neuropsychiatric manifestations. 1
Critical Pitfalls to Avoid
Never dismiss bizarre symptoms as "just psychiatric" without adequate medical workup, as this can miss life-threatening conditions including CNS infections, metabolic encephalopathy, substance withdrawal, and autoimmune disorders. 2, 3
Do not fail to document these symptoms out of concern they seem "too bizarre"—the bizarreness itself is diagnostically significant and may indicate serious underlying pathology. 1
Avoid attributing altered mental status solely to psychiatric causes without ruling out medical etiologies, as mortality doubles when delirium is missed in favor of psychiatric diagnosis. 3
Do not omit documentation of the specific content and characteristics of delusions, as certain features (such as physical impossibility or cultural incomprehensibility) have diagnostic significance. 4