Disturbed or agitated patient

Question 1

Probability diagnosis

Answer 1

The 4 Ds:

dementia

delirium (look for cause)

depression

drugs: toxicity, withdrawal

Question 2

Serious disorders not to be missed

Answer 2

Cardiovascular:

• CVAs
• cardiac failure
• arrhythmia
• acute coronary syndromes

Neoplasia/cancer:

• cerebral
• cancer (e.g. lung)

Infection:

• septicaemia
• HIV infection
• infective endocarditis

Hypoglycaemia/diabetic ketoacidosis

Bipolar disorder/mania

Schizophrenia states

Anxiety/panic

Subdural/extradural haematoma

Question 3

Pitfalls (often missed)

Answer 3

1. Alcohol intoxication/withdrawal
2. Illicit drug withdrawal (e.g. amphetamines)
3. Fluid and electrolyte disturbances
4. Faecal impaction (elderly)
5. Urinary retention (elderly)
6. Hypoxia
7. Pain syndromes (elderly)
8. Rarities:

• postictal state
• hypocalcaemia
• kidney failure
• hepatic failure
• prion diseases (e.g. Creutzfeldt-Jakob disease)

Question 4

Masquerades checklist

Answer 4

Depression

Diabetes (hypo and hyperglycaemia)

Drugs: iatrogenic/social illicit (see list)

Anaemia

Thyroid disorder (hypo and hyper)

Spinal dysfunction (severe pain in elderly)

UTI

Question 5

Is the patient trying to tell me something?

Answer 5

Consider

1. anxiety
2. depression
3. emotional deprivation or upset
4. change in environment
5. serious personal loss.

Question 6

Key history

Answer 6

Accurate account from relatives or witnesses about the pt’s behaviour.

When communicating with pt, speak slowly and simply, face them and maintain eye contact.

Note PMHx and recent psychosocial history, including recent bereavement, family upsets and changes in environment.

Drug history is vital.

Perform a mini mental status examination.

Question 7

Key examination

Answer 7

Note the pt’s general demeanour, dress and physical characteristics

Check vital signs

Assess ability to hear, speak, reason, obey commands, stand and walk

Look for features of alcohol abuse, Parkinson disease and hypothyroidism

Examine the neurological systems

Pulse oximetry (if available)

Question 8

Key investigations

Answer 8

For delirious or demented patients of unknown cause consider:

• MCU urine
• blood culture
• FBE/ESR
• blood glucose
• U&E, calcium and phosphate
• B12 and folate, vitamin D
• TFTs
• LFTs
• HIV test
• arterial blood gases
• CXR
• cerebral CT scan.

Question 9

Diagnostic tips

Answer 9

The cause may be single or multiple.

Psychiatric causes include panic disorder, mania, major depression and schizophrenia.

The key feature of dementia is impaired memory.

The two key features of delirium are disorganised thought and inattention.

Prescribed drugs that can cause antisocial behaviour:

• major and minor tranquilisers
• anti-Parkinson
• cardiogenic
• corticosteroids.