You are at the local mall and you see a patient who appears to be homeless by his physical appearance
and you witness the person “walk 50 feet to a table sit down, and after 5 seconds he gets up and walks
to a tree and urinates on it” He repeats this action 5 times apparently oblivious to his surroundings.
When the police come he ignores them as if they aren’t there. Later, you go to work and sitting in exam
room 3 is the same person! Now, he is your patient, when you talk to him he has no recollection of his
behavior by the mall.
What is your differential diagnosis?
• Alcohol Abuse – Alcohol effects the way the brain thinks and interferes with the brain’s
communication pathways and this can cause changes in behaviors (Alcohol abuse, 2015). Seeing
that the patient has no recollection of the incident it is possible that he could have suffered a
temporary blackout or memory loss (Signs and symptoms, 2015). Again, further testing is
needed but alcohol abuse is a possibility.
• Schizophrenia – a chronic brain disease that causes a variety of symptoms in various degrees.
Schizophrenia can often cause disordered thinking and thus changes the way people think
(Schizophrenia, 2016). Scientists believe that there is an imbalance of the neurotransmitters
called dopamine and glutamate that could contribute to the cause of schizophrenia
(Schizophrenia, 2016). The patient exhibits disorganized thought that could be a possibility of
schizophrenia but further testing needs to be completed.
• Urinary Tract Infection (UTI) – a UTI can often cause unusual behaviors that mimic dementia or a
delirium-like state in the elderly (Can a urinary tract infection cause strange behavior?, 2014).
With the unusual symptoms that the patient showed it is possible to have a UTI and checking his
urine is worth ruling it out.
What tests do you order?
I would choose to do lab work such as a UA, complete blood count, and alcohol and drug screening. I
would also do an MRI to rule the possibility of any tumors or lesions in the brain (Schizophrenia tests
and diagnosis, 2014). The important to rule out any physical illnesses that could contribute to
psychiatric symptoms.
An MRI comes back and there seems to be a lesion in the temporal lobe does this change your
differential? The EEG also comes back with unusual excitatory activity. What is your definitive
diagnosis? In retrospect did anything bias your first differential?
I believe that I was initially biased to the fact that the patient’s description was described as appearing
homeless. We often think that just because someone is homeless that they either drink alcohol or have
a mental illness. Therefore, my initial diagnoses are incorrect and I would change it to epilepsy. Epilepsy
is often can often present as confusion or memory lapses, especially in the elderly (Ko, 2014). People
with temporal lobe epilepsy often present with repetitive behavior and often have amnesia during a
complex partial seizure because of bilateral hemispheric involvement (Ko, 2014).
and you witness the person “walk 50 feet to a table sit down, and after 5 seconds he gets up and walks
to a tree and urinates on it” He repeats this action 5 times apparently oblivious to his surroundings.
When the police come he ignores them as if they aren’t there. Later, you go to work and sitting in exam
room 3 is the same person! Now, he is your patient, when you talk to him he has no recollection of his
behavior by the mall.
What is your differential diagnosis?
• Alcohol Abuse – Alcohol effects the way the brain thinks and interferes with the brain’s
communication pathways and this can cause changes in behaviors (Alcohol abuse, 2015). Seeing
that the patient has no recollection of the incident it is possible that he could have suffered a
temporary blackout or memory loss (Signs and symptoms, 2015). Again, further testing is
needed but alcohol abuse is a possibility.
• Schizophrenia – a chronic brain disease that causes a variety of symptoms in various degrees.
Schizophrenia can often cause disordered thinking and thus changes the way people think
(Schizophrenia, 2016). Scientists believe that there is an imbalance of the neurotransmitters
called dopamine and glutamate that could contribute to the cause of schizophrenia
(Schizophrenia, 2016). The patient exhibits disorganized thought that could be a possibility of
schizophrenia but further testing needs to be completed.
• Urinary Tract Infection (UTI) – a UTI can often cause unusual behaviors that mimic dementia or a
delirium-like state in the elderly (Can a urinary tract infection cause strange behavior?, 2014).
With the unusual symptoms that the patient showed it is possible to have a UTI and checking his
urine is worth ruling it out.
What tests do you order?
I would choose to do lab work such as a UA, complete blood count, and alcohol and drug screening. I
would also do an MRI to rule the possibility of any tumors or lesions in the brain (Schizophrenia tests
and diagnosis, 2014). The important to rule out any physical illnesses that could contribute to
psychiatric symptoms.
An MRI comes back and there seems to be a lesion in the temporal lobe does this change your
differential? The EEG also comes back with unusual excitatory activity. What is your definitive
diagnosis? In retrospect did anything bias your first differential?
I believe that I was initially biased to the fact that the patient’s description was described as appearing
homeless. We often think that just because someone is homeless that they either drink alcohol or have
a mental illness. Therefore, my initial diagnoses are incorrect and I would change it to epilepsy. Epilepsy
is often can often present as confusion or memory lapses, especially in the elderly (Ko, 2014). People
with temporal lobe epilepsy often present with repetitive behavior and often have amnesia during a
complex partial seizure because of bilateral hemispheric involvement (Ko, 2014).
