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Surgical sieve
🧠 Confusion / delirium
Delirium is a symptom, not a diagnosis. Work the causes: PINCH ME. If the conscious level is DEPRESSED rather than the thinking disordered, use the Drowsy / reduced GCS card instead — that one leads on airway, glucose and pupils, because the airway is at risk.
| Hypoglycaemia Must exclude | Any confused patient. Fully reversible and rapidly fatal if missed.Check a glucose in EVERY confused patient, immediately. |
|---|---|
| Hypoxia Must exclude | Agitation is often the first sign of hypoxia — before the patient looks blue.Saturations and ABG. |
| Sepsis Must exclude | In the elderly, confusion may be the ONLY sign of sepsis — often without fever.Full septic screen, Sepsis 6 if suspected. |
| Meningitis / encephalitis Must exclude | Headache, photophobia, neck stiffness, fever, rash. Encephalitis: personality change, seizures.Blood cultures, antibiotics ± aciclovir before LP if delay. |
| Intracranial haemorrhage Must exclude | Focal signs, headache, reduced GCS. Anticoagulated patients after minor falls.Urgent CT head — within 1h if anticoagulated or GCS drop. |
| Stroke Must exclude | Sudden onset focal deficit. Posterior circulation strokes can present as pure confusion.CT head, thrombolysis window. |
| Drug toxicity or withdrawal Time-sensitive | Opioids, benzodiazepines, anticholinergics, steroids. Alcohol withdrawal at 24–72h.Review the drug chart — the commonest reversible cause in hospital. |
| Urinary retention or constipation Time-sensitive | Classic and frequently missed causes of agitation in the frail elderly.Bladder scan and PR examination before sedating anyone. |
| Electrolyte derangement Time-sensitive | Hyponatraemia, hypercalcaemia, uraemia. Often subacute and easily corrected.U&Es, calcium, magnesium, phosphate. |
| Urinary tract infection Common | Common — but overdiagnosed. Asymptomatic bacteriuria is not a cause of delirium.Do not anchor here. Exclude other causes first. |
| Pain Common | Undertreated pain, especially post-operative or fracture, causes agitation. |
| Wernicke's encephalopathy Time-sensitive | Confusion, ophthalmoplegia, ataxia in alcohol excess or malnutrition.IV Pabrinex BEFORE any glucose. |
| Hypothyroidism / hyperthyroidism Consider | Myxoedema: hypothermia, bradycardia. Thyroid storm: fever, AF, agitation. |
| Dementia (baseline) Consider | Establish the baseline from a collateral history. Acute-on-chronic is still delirium.Collateral history is essential — 4AT for screening. |
14 differentials · 7 open a full pathway in the app.