The clinician focuses entirely on the physical symptoms.

• He does not pay attention to the timeline of the complaint – it is a new change from this mans normal mental status.
• He does not listen to concerns from family members that there may be “something else” wrong.
• He did no formal psychiatric assessment.
• He did not assess the patient for suicidal or homicidal ideation.

This patient went home, and that night took a mixed overdose of all his medication, spent seven days in the ICU, and eventually required long-term care because of his hypoxic acquired brain injury.

Legal action was commenced by his family.

The clinician asks “What has changed? What is different”.

• He established the timeline of the cognitive impairment by teasing out the chronic from the acute changes.
• He seems to be aware of the components of delirium and is using the Confusion Assessment Method (CAM) to screen for it.
• He has an approach to the assessment of delirium.

While this did take slightly longer, the outcome is significantly different.

This patient had a complete delirium work-up which detected an acute-on-chronic subdural hematoma (from a recent unwitnessed fall). It was drained. She was discharged home at her baseline function in a week.