Disturbed or agitated patient Flashcards
Probability diagnosis
The 4 Ds:
dementia
delirium (look for cause)
depression
drugs: toxicity, withdrawal
Serious disorders not to be missed
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
Pitfalls (often missed)
- Alcohol intoxication/withdrawal
- Illicit drug withdrawal (e.g. amphetamines)
- Fluid and electrolyte disturbances
- Faecal impaction (elderly)
- Urinary retention (elderly)
- Hypoxia
- Pain syndromes (elderly)
- Rarities:
- postictal state
- hypocalcaemia
- kidney failure
- hepatic failure
- prion diseases (e.g. Creutzfeldt-Jakob disease)
Masquerades checklist
Depression
Diabetes (hypo and hyperglycaemia)
Drugs: iatrogenic/social illicit (see list)
Anaemia
Thyroid disorder (hypo and hyper)
Spinal dysfunction (severe pain in elderly)
UTI
Is the patient trying to tell me something?
Consider
- anxiety
- depression
- emotional deprivation or upset
- change in environment
- serious personal loss.
Key history
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.
Key examination
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)
Key investigations
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.
Diagnostic tips
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.