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Probability diagnosis

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Drugs: illicit or prescribed

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Alcohol: acute or chronic

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Schizophrenia

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Febrile delirium

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Affective (mood) disorders

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Drug withdrawal inc. alcohol, hypnotics

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Dementias esp. Lewy body disease

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Serious disorders not to be missed

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Vascular:

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  • Cerebrovascular disease

  • Migraine (luminous)

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Infection:

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  • Encephalitis/meningitis

  • Septicaemia

  • Any serious febrile illness

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Tumours:

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  • Cerebral tumours

  • Cancer treatment

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Other:

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  • Hypoxia

  • Liver failure

  • Metabolic/electrolyte imbalance

  • Dehydration

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Pitfalls (often missed)

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Major depression

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Extreme fatigue

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Vitamin deficiency esp. B group

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Seizure disorders esp. complex partial

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Rarities:

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  • Narcolepsy

  • Post-concussion

  • Bereavement

  • Multiple sclerosis

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Masquerades checklist

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Depression

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Diabetes

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Drugs: iatrogenic/social–illicit

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Thyroid/other endocrine: hypothyroid?

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Urinary tract infection esp. elderly

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Is the patient trying to tell me something?

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Consider conversion disorder (hysteria); fabrication.

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Key history

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A careful history is required, esp. current history incl. general health, febrile illness, psychological issues, neurological features, nutrition and head injury. Elicit type of hallucination: auditory, visual, olfactory, tactile, hypnogogic or hypnopomic. Examine past, family and psychosocial history, as well as any history of cerebrovascular disease, diabetes, hypertension or migraine. Check thyroid symptoms, particularly for hypothyroidism. Also examine drug history: prescribed; OTC; alcohol; social esp. marijuana, opioids, amphetamines, LSD, petrol sniffing.

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Key examination

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  • General features: appearance 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

  • KFTs

  • cerebral imaging

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Diagnostic tips

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Pay close attention to drugs use, esp. alcohol, caffeine, narcotics and illicit agents

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Auditory hallucinations – incl. schizophrenia; depression; bereavement.

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Visual: organic disease

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Olfactory: complex partial seizures (temporal lobe)

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Tactile: drugs (alcohol, opioids e.g. cocaine, amphetamines esp. ‘ice’)

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