Family medicine
Acute Confusion / Delirium
Acute, fluctuating disturbance in attention, awareness, and cognition, typically caused by an underlying medical condition, substance use, or withdrawal.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Delirium secondary to UTI | Acute confusion + fever + dysuria in elderly | 「有冇發燒、小便痛、小便臭？」 |
| Delirium secondary to pneumonia | Cough, fever, tachypnoea, desaturation | 「有冇咳？痰多唔多？」 | |
| Drug-induced delirium | Temporal link to new/changed medication | 「最近有冇食新藥或者轉藥？」 | |
| Serious Not To Miss | Stroke / Intracranial bleed | Focal neurological deficit, sudden onset | 「有冇一邊手腳冇力？」Focal weakness on exam |
| Subdural haematoma | History of fall/head injury, on anticoagulants | 「最近有冇跌親？食緊薄血丸？」 | |
| Meningitis / Encephalitis | Fever + headache + neck stiffness + photophobia | 「有冇頭痛、怕光？」Neck stiffness on exam | |
| Hypoglycaemia | Known DM, on insulin/SU, sweaty, tremor | 「有冇糖尿病？有冇出冷汗、手震？」CBG check | |
| Myocardial infarction / PE | Chest pain, dyspnoea, hypoxia in elderly — can present as confusion | 「有冇胸口痛、氣喘？」 | |
| Pitfalls | Hyponatraemia | Diuretics, SIADH, vomiting; insidious confusion | 「食緊去水丸？有冇嘔？」Check Na |
| Hypercalcaemia | Malignancy, hyperPTH; "bones, stones, groans, moans" | 「有冇骨痛？便秘？飲好多水？」[6] | |
| Urinary retention / Faecal impaction | Easily missed, easily treated | 「小便順唔順？幾日冇大便？」Palpate bladder | |
| Non-convulsive status epilepticus | Subtle seizure activity, requires EEG | Prolonged unresponsiveness after seizure; EEG needed [2] | |
| Masquerades | Dementia (esp. DLB) | Insidious onset, months-years; DLB has visual hallucinations + parkinsonism + fluctuation [7] | 「記性差咗幾耐？幾個月定幾日？」 |
| Depression (pseudodementia) | Low mood, anhedonia, psychomotor retardation mimicking hypoactive delirium | 「心情點？有冇唔開心？」 | |
| Hepatic encephalopathy | Known liver disease, flapping tremor, fetor hepaticus | 「有冇肝病？」Check for asterixis [8] | |
| Drugs / alcohol withdrawal | Timing after cessation, autonomic features, tremor | 「幾時停咗飲酒？有冇手震、出汗？」 | |
| Trying to Tell Me Something? | Carer burnout / requesting placement | Family member unable to cope | 「你照顧佢辛唔辛苦？有冇諗過其他安排？」 |
| Fear of dementia diagnosis | Anxiety about permanence of cognitive decline | 「你擔唔擔心佢係老人痴呆？」 | |
| Elder abuse / neglect | Unexplained injuries, malnutrition, unkempt | 「佢身上有冇傷？食嘢夠唔夠？」Check for bruises |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生。今日想了解吓你嘅情況，可以傾大約六分鐘，有咩都可以講㗎。」 | Interpersonal marks: greeting, permission, time-frame |
| 0:30–1:30 | Chief complaint & HPI — onset, duration, fluctuation, course; who noticed the confusion; baseline cognition | 「可唔可以講吓幾時開始覺得唔妥？」「係突然間定慢慢嚟㗎？」「有冇時好時壞？」「平時記性點㗎？」 | Core history: acute onset + fluctuating = delirium hallmark [1][2] |
| 1:30–2:30 | Symptom analysis & red flags — fever, dysuria, cough, headache, focal weakness, recent falls/head injury, drugs/alcohol, recent surgery/admission, pain, constipation/retention | 「有冇發燒？」「小便痛唔痛？」「有冇咳？」「有冇跌親撞親個頭？」「飲唔飲酒？食緊咩藥？」 | Identifies precipitant; red flags for serious causes |
| 2:30–3:30 | PMHx, DHx, allergy, social Hx — dementia, DM, liver/renal disease, polypharmacy, Beers-list drugs, living situation, carer, ADL, smoking, alcohol | 「之前有冇長期病？」「食緊幾多種藥？最近有冇轉藥？」「屋企有冇人照顧？」 | Dementia is leading RF for delirium [3]; polypharmacy/drugs are common precipitants |
| 3:30–4:30 | ICE — Ideas, Concerns, Expectations | 「你自己覺得點解會咁？」(Idea)「你最擔心啲咩？」(Concern)「你嚟睇醫生最希望我幫到咩？」(Expectation) | Direct marks on Case Report Form Q3 |
| 4:30–5:15 | Hidden agenda probe + functional impact | 「仲有冇其他嘢想同我講？」「呢件事對你日常生活有咩影響？」「照顧嘅人辛唔辛苦？」 | Uncovers carer stress, elder abuse, fear of dementia diagnosis |
| 5:15–6:00 | Summarise, signpost, safety-net, close | 「咁我總結吓：你/你屋企人最近突然間意識唔清楚…我會幫你安排檢查搵原因。如果情況惡化，例如發高燒、抽筋或者完全叫唔醒，要即刻去急症。」 | Summarising + safety-net = high interpersonal marks |
Hidden agenda tip: The SP may be a family member/carer, not the patient. The real concern is often "Is this dementia?" or "Am I coping?" or guilt about wanting residential care. Always ask: 「你自己辛唔辛苦？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/course | When did the confusion start? Sudden or gradual? | 「幾時開始嘅？突然定慢慢嚟？」 | Acute onset and fluctuating course is the hallmark that distinguishes delirium from dementia [1][2] | Delirium (acute); dementia (insidious) |
| Fluctuation | Does it come and go? Worse at night? | 「有冇時好時壞？夜晚有冇差啲？」 | Diurnal fluctuation, worse at night is classic delirium [3] | Delirium; also DLB fluctuates |
| Attention | Can they follow a conversation? Easily distracted? | 「佢傾偈嗰陣會唔會好容易分心？」 | Impaired attention is the hallmark of delirium [1][2][3] | Delirium |
| Baseline cognition | Was memory/cognition normal before this? Any prior dementia Dx? | 「之前記性好唔好？有冇睇過腦科？」 | Dementia is the leading risk factor for delirium [3]; delirium superimposed on dementia is common | Dementia + superimposed delirium |
| Fever/infection | Any fever, cough, painful urination? | 「有冇發燒、咳、小便痛？」 | UTI and chest infection are the most common precipitants in elderly [4] | UTI, pneumonia, CNS infection |
| Drugs | Any new medications? Sleeping pills? Painkillers? Recent changes? | 「最近有冇食新藥？安眠藥？止痛藥？轉過藥？」 | Drugs (anticholinergics, opioids, BZD, steroids) are a major reversible cause [3][5] | Drug-induced delirium |
| Alcohol | How much alcohol? When was the last drink? | 「飲唔飲酒？飲幾多？最後一次幾時飲？」 | Alcohol withdrawal delirium (delirium tremens) typically 48–72h after last drink | Delirium tremens, Wernicke's |
| Head injury/fall | Any recent fall or head injury? | 「最近有冇跌親或者撞親個頭？」 | Subdural haematoma — must not miss in elderly, especially on anticoagulants | SDH, intracranial bleed |
| Focal neuro Sx | Any weakness on one side, slurred speech, seizures? | 「有冇手腳冇力、講嘢唔清楚、抽筋？」 | Stroke, NCSE, space-occupying lesion | CVA, brain tumour, NCSE |
| Metabolic | Any diabetes? Eating/drinking less? | 「有冇糖尿病？呢幾日有冇食嘢飲水少咗？」 | Hypoglycaemia, dehydration, electrolyte imbalance [6] | Hypo/hyperglycaemia, hypoNa, hypercalcaemia |
| Urinary retention/constipation | Any difficulty passing urine? Bowels? | 「小便暢唔暢順？有冇便秘？」 | Retention of urine or faeces — easily reversible precipitant (DELIRIUM mnemonic) [3] | Urinary retention, faecal impaction |
| PMHx | Any liver, kidney, thyroid, heart disease? | 「有冇肝病、腎病、甲狀腺、心臟病？」 | Hepatic encephalopathy, uraemia, myxoedema, heart failure | Organ failure |
| Visual/auditory hallucinations | Seeing or hearing things not there? | 「有冇見到啲嘢唔存在嘅？或者聽到啲聲？」 | Visual hallucinations especially suggest delirium or DLB [2][3] | Delirium (VH common), DLB |
| Carer/social | Who lives with patient? Who is the main carer? Can they cope? | 「屋企有邊個照顧佢？你哋應唔應付到？」 | Social problem; carer burnout — marks in biopsychosocial | Carer stress, need for social support |
| Functional impact | Can patient still do daily activities (eating, toileting, walking)? | 「佢仲可唔可以自己食飯、去廁所、行路？」 | ADL decline = severity marker; discharge planning | Need for home help / residential care |
Case Report Form Answer Builder
- CC: "Acute confusion for [X days]" — state duration
- HPI high-yield points:
- Onset (acute = hours-days), course (fluctuating), baseline cognition
- Precipitating factors found: fever, new drug, fall, reduced oral intake
- Associated Sx: hallucinations, agitation/drowsiness, incontinence, reduced ADLs
- Relevant PMHx: dementia, DM, CKD, liver disease, recent hospitalization/surgery
- Drug & alcohol history
- Informant source (patient usually cannot give reliable history — note who gave it)
- Most likely: "Family member / carer brought patient because of sudden change in behaviour/cognition over [X days], worried about the cause and whether patient needs hospitalization"
- Phrase as: "Acute onset of confusion noticed by family, seeking diagnosis and management"
- Alternative: "Carer unable to cope with patient's behaviour at home"
| Likely Content | Example Wording | |
|---|---|---|
| Ideas | "I think it might be dementia / stroke / side effect of medication" | 「佢覺得可能係老人痴呆 / 中風 / 藥物副作用」 |
| Concerns | "Worried this is permanent / worried about brain tumour / worried cannot cope at home" | 「擔心佢會唔會變返正常 / 擔心係腫瘤 / 擔心照顧唔到」 |
| Expectations | "Wants brain scan / wants admission / wants medication to calm patient" | 「想照吓腦 / 想入院檢查 / 想醫生開藥鎮靜佢」 |
- Delirium (secondary to [precipitant, e.g., UTI / pneumonia / drug-related])
- Minimum supporting evidence:
- Acute onset (hours-days, not months)
- Fluctuating course (worse at night)
- Inattention (cannot follow conversation / easily distracted)
- Identified precipitant (e.g., fever + dysuria → UTI)
- Write: "Delirium secondary to urinary tract infection" (or whichever precipitant the stem suggests)
| DDx | One Key Discriminator |
|---|---|
| Dementia (e.g., Alzheimer's / DLB) | Insidious onset over months–years; no acute fluctuation (except DLB which has visual hallucinations + parkinsonism) |
| Stroke / Intracranial pathology (SDH, tumour) | Focal neurological deficit; sudden onset; history of fall or anticoagulant use |
| Drug-induced / Alcohol withdrawal | Temporal correlation with new medication or cessation of alcohol; autonomic features in withdrawal |
| Domain | Problem |
|---|---|
| Biological | Acute delirium with risk of falls, aspiration, dehydration; underlying precipitant (e.g., UTI) requiring treatment |
| Psychological | Patient's distress from hallucinations/confusion; carer's anxiety and fear of permanent cognitive decline |
| Social | Carer burden / inability to supervise confused patient at home; may need temporary or long-term residential care; ADL decline affecting independence |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Delirium (most likely Dx) | Inattention on bedside testing — cannot do serial 7s or spell WORLD backwards; fails digit span | Ask patient to count backwards from 20, or spell「世界」backwards, or do months-of-year backwards | Inattention is the hallmark of delirium [1][2][3]; presence with acute onset + fluctuation fulfills CAM criteria |
| Dementia (DDx) | Impaired short-term memory with preserved attention initially; MMSE/MoCA score low but patient alert and attentive | Delayed recall testing (e.g., 3-item recall); clock drawing test | Progressive memory loss without acute fluctuation or impaired consciousness |
| Stroke / SDH (DDx) | Focal neurological deficit (hemiparesis, facial droop, visual field cut) | Motor exam: pronator drift, grip strength, facial symmetry; visual field by confrontation | Focal signs suggest structural brain lesion — warrants urgent imaging |
| Drug / alcohol withdrawal (DDx) | Autonomic hyperactivity: tremor, tachycardia, diaphoresis | Observe for resting tremor; check pulse rate; feel skin for moisture | Sympathetic overdrive is classic in withdrawal states |
| Hepatic encephalopathy (DDx) | Asterixis (flapping tremor) + fetor hepaticus | Ask patient to dorsiflex wrists with arms outstretched; observe for flap; smell breath | Asterixis is characteristic of metabolic encephalopathy, especially HE [8] |
| Meningitis / encephalitis (DDx) | Neck stiffness (meningism) + fever | Passive neck flexion — check for resistance; Kernig's and Brudzinski's signs | Meningism + fever + confusion = CNS infection until proven otherwise |
Top Traps That Lose Marks
- Assuming confusion in the elderly = dementia. Delirium is acute onset; dementia is insidious. Always ask about time course.
- Forgetting to identify the precipitant. "Delirium" alone is incomplete — the mark goes to "Delirium secondary to [cause]."
- Not asking about drugs / alcohol. Drug-induced and withdrawal states are among the most common and reversible causes [3][5].
- Interviewing the confused patient alone. You need a collateral history from the carer/family. State this on the case report.
- Missing urinary retention / faecal impaction — easily reversible precipitants that are commonly overlooked.
- Forgetting ICE of the carer — in this station the SP is often a family member, not the patient.
- Not performing or mentioning CAM as the screening tool — it is the most widely used instrument for delirium identification [1][2][9].
Must-Not-Miss Red Flags → Urgent Referral
- Fever + neck stiffness + confusion → meningitis/encephalitis → A&E immediately
- Focal neurological deficit → stroke / intracranial bleed → A&E for urgent CT brain
- Hypoglycaemia (CBG < 4) → immediate glucose
- Severe agitation with risk of harm to self or others → A&E
- GCS ≤ 8 / unrousable → 999 / A&E
- Suspected overdose / poisoning → A&E with drug history
Shortest safe management/safety-net line for closing: 「我會轉介你去急症/專科做進一步檢查，包括驗血、驗小便，可能要照腦。如果佢突然間叫唔醒、抽筋、或者發高燒，要即刻打999去急症室。」
High Yield Summary
What to ASK: Onset (acute vs insidious), fluctuation, baseline cognition, attention, precipitants (infection, drugs, metabolic, retention, fall), alcohol, collateral history from carer, ICE of carer.
What to WRITE: CC = "Acute confusion for X days." Dx = "Delirium secondary to [precipitant]." Support with CAM criteria: acute onset + fluctuation + inattention + (disorganised thinking OR altered consciousness). ICE must reflect carer's perspective. Biopsychosocial must include carer burden.
What NOT to MISS: Collateral history. The precipitant. Drugs/alcohol. Focal neurology (→ stroke/SDH). Fever + neck stiffness (→ meningitis). Hypoglycaemia. CAM as the screening tool. Urinary retention/constipation.
Active Recall - Family Medicine Clinical Test
[1] GC 037. Common neurological problems in older people.pdf (slides on Delirium definition and CAM criteria) [2] GC 081. Seizure and loss of consciousness Delirium and encephalopathy; epilepsy; coma and brain death.pdf [3] Ryan Ho Psychiatry.pdf (Section 4.1 Delirium, DELIRIUM mnemonic, precipitating factors) [4] Maksim Medicine Notes.pdf (Geriatrics section — Causes of confusion in elderly) [5] GC 079. Prescribing in older people.pdf (Beers criteria, inappropriate medications) [6] Block A - Confused and dehydrated: hypercalcaemia; hypocalcaemia.pdf [7] GC 241. Reference (3) - Patel dementia with lewy bodies.pdf [8] Block A - A jaundiced and incoherent patient: liver failure.pdf (hepatic encephalopathy DDx) [9] Delirium in Elderly People_Lancet.pdf (CAM validation, diagnostic features)
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