Although a standard psychiatric evaluation includes a physical examination, there are no guidelines on the components of a comprehensive physical examination during psychiatric patient encounters. The mental status examination is frequently considered the psychiatric physical examination equivalent. We report a 59-year-old male inpatient on a medical unit who had hyperthermia, an altered mental status, muscle rigidity, and elevated white blood cell count and creatine phosphokinase level. He had been taking risperidone 1 mg orally every 12 hours for two months. His primary treatment team suspected Neuroleptic Malignant Syndrome (NMS), but the consulting psychiatrist detected equivocal findings on physical examination and recommended a broader differential diagnosis. Further investigations revealed the possibility of an infection. The patient was positive for immunoglobulin G (IgG) antibodies to HSV-1 and HSV-2 on cerebrospinal fluid analysis. He was then treated for Herpes Simplex Encephalitis (HSE) with an oral course of acyclovir. Although NMS was low in the diagnostic ranking, given the possibility of an atypical form and the lethality of this condition if untreated, he also received intravenous lorazepam at 2 mg every six hours. He experienced full resolution of his symptoms and was stable for discharge. HSE and NMS are two examples of neuropsychiatric disorders with similar presenting symptoms. HSE frequently presents with predominantly psychiatric symptoms, such as paranoia, hallucinations, and an altered mental status. Consequently, it is typically not the first diagnosis that comes to mind, especially when these symptoms occur in a patient already being treated by a psychiatrist. Confirmation bias is the tendency for an individual to focus on the information that aligns with one's preconceptions and to ignore information that defies it. Due to this bias, physicians may attribute all symptoms of a known psychiatric patient to a psychiatric cause, instead of considering an organic etiology. In this case, the evaluation by the psychiatrist was crucial in guiding the treatment team to a diagnosis of HSE. This is important since a delayed treatment of HSE can be fatal. The literature review reveals a general consensus among psychiatrists on the value of physical examinations in patient care. In spite of this, the majority of psychiatrists seldom perform physical examinations due to concerns over skill atrophy and the potential that doing so may change the therapeutic dynamic. Others have disputed these claims and have argued that physical examinations in a psychiatric setting will not only strengthen the perception of a psychiatrist as a physician by the patient but will also allow for better care of psychiatrically ill patients. Psychiatrists should remember that they are oftentimes the sole healthcare provider for psychiatric patients and that these patients may not have the access to primary care physicians and may lack the ability to explain their symptoms or advocate for themselves. Therefore, incorporating an emphasis on performing physical examinations during psychiatry residency training and in continuing medical education programs for psychiatrists is essential.
Keywords: herpes simplex encephalitis; neuroleptic malignant syndrome; neuropsychiatric symptoms; physical examination; psychiatry.