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++

Probability diagnosis

++

Severe anxiety/stress

++

Major depression esp. post ECT

++

Ageing/dementia

++

Head injury

++

Alcohol excess incl. Korsakoff syndrome

++

Iatrogenic e.g. ECT, cardiac bypass surgery

++

Serious disorders not to be missed

++

Vascular:

++

  • Cerebral haemorrhage/subarachnoid

  • Cerebral infarction esp. vertebrobasilar

++

Infection:

++

  • Cerebral e.g. meningitis, abscess

  • Viral encephalitis e.g. Herpes Simplex

  • Syphilis

  • HIV/AIDS

++

Tumor/cancer:

++

  • Cerebral tumour

  • Paraneoplasia

++

Other:

++

  • Anoxia/hypoxia

  • Hypothermia

  • Electrolyte disturbance esp. hyponatraemia

  • Dehydration

  • Post-ictal state

++

Pitfalls (often missed)

++

Transient global amnesia

++

B1 deficiency incl. alcohol abuse

++

Dissociative fugue states

++

Depersonalisation disorder

++

Rarities:

++

  • Wernicke’s encephalopathy

  • Carbon monoxide poisoning

++

Masquerades checklist

++

Depression esp. major

++

Diabetes: hypoglycaemia

++

Drugs: various e.g. Cannabis, amphetamines (see list)

++

Anaemia

++

Thyroid/other endocrine: hypercalcaemia/hypothyroid?

++

Is the patient trying to tell me something?

++

Conversion reaction (hysterical fugue)

++

Psychogenic amnesia/malingering

++

Key history

++

A careful history is required recording the nature of memory loss incl. onset, duration, fluctuation and associations. Interview family members and check for possible bizarre behaviour. The key history should incl. past medical history including diabetes, hypertension, cerebrovascular disease; drug history esp. alcohol, smoking or illicit drugs (cannabis, amphetamines, opioids, solvent sniffing), lithium, barbiturates, benzodiazepines, anticonvulsants, digoxin, OTC drugs, etc.; and psychiatric history, incl. severe anxiety, stress, depression, fugue features, dissociation or personality disorder.

++

Key examination

++

  • General features: appearance of patient incl. central cyanosis, hydration status, vital signs

  • Psychiatric assessment and mental state examination

  • Neurological examination

++

Key investigations

++

First line:

++

  • urinalysis

  • blood sugar

  • pulse oximetry

  • FBE & ESR

  • LFTs (γGT)

  • Others according to history and findings

++

Consider:

++

  • blood gases

  • TFTs

  • syphilis serology

  • CXR

  • imaging: cerebral CTscan or MRI

++

Diagnostic tips

++

Consider memory loss as a presenting feature of severe stress, anxiety or depression (which can present as pseudo dementia in the elderly).

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