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Probability diagnosis

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Functional: no medical or mental component

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Drugs: alcohol, illicit (see list) or prescribed

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Alcohol: acute or chronic

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Antisocial personality disorder esp. cluster B

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Affective (mood) disorders

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Drug withdrawal incl. alcohol, hypnotics

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Mental impairment

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Serious disorders not to be missed

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Vascular:

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  • Cerebrovascular disease including SAH

  • Acute coronary syndromes

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Infection:

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  • Encephalitis/meningitis

  • HIV/AIDS

  • Septicaemia

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Tumours:

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  • Cerebral tumours

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Other:

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  • Post ictal (epilepsy)

  • Delirium

  • Subdural haematoma

  • Psychosis: schizophrenia, bipolar, paraphrenia

  • Schizotypal personality disorder

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Pitfalls (often missed)

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Head injury

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Fluid and electrolyte imbalance

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Dementia esp. early

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Rarities:

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  • Neurosyphilis

  • Prion disease e.g. CJD

  • Premenstrual dysphoria syndrome

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Masquerades checklist

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Depression—major

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Diabetes: hypoglycaemia

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Drugs: iatrogenic/social–illicit

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Thyroid/other endocrine: hyper/hypothyroid

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Is the patient trying to tell me something?

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Consider conversion disorder (hysterical fugue)

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Malingering/fabrication

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Severe anxiety/panic

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Key history

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  • Nature of behaviour and precipitants, associations

  • Psychiatric history: anxiety, OCD, depression, hypomania, personality traits, fugue features

  • Past, family and psychosocial history, developmental history, epilepsy, Parkinson disease, family history

  • Drug history: prescribed (see list), OTC, alcohol, social/illicit drugs (see list)

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Key examination

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This is limited.

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  • General features: appearance and behaviour of patient, vital signs

  • General respiratory, neurological and cardiovascular examination

  • Pulse oximetry

  • Mental state examination

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Key investigations

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First line:

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  • urinalysis

  • blood glucose

  • FBE

  • U&E

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Consider:

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  • LFTs (γGT)

  • ECG

  • TFTs

  • KFTs

  • cerebral imaging

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Diagnostic tips

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Pay close attention to drug use esp. alcohol, caffeine, narcotics and amphetamines e.g. ‘ice’

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Prescribed drugs: major and minor tranquilisers, anti-Parkinson, cardiogenic, corticosteroids.

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Non-prescribed drugs: marijuana, LSD, opioids, amphetamines, ecstasy, cocaine, gamma hydroxybutyrate (‘fantasy’), solvents e.g. petrol sniffing.

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Cluster B antisocial personality disorders incl. histrionic, narcissistic and borderline.

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