The Confused Man Who Won't Answer
You are called to a hostel at 02:00 to a 61-year-old man found confused on the floor of his room. Staff say he has diabetes and takes insulin but they do not know when he last ate. He is drowsy, slurring his words, and smells of alcohol. He is resistive to examination, pulls his arm away, and tells you to 'get lost'. He has a small laceration to his forehead with dried blood but no active bleeding. Vital signs: pulse 104, respiratory rate 18, blood pressure 150/90, SpO2 96%, temperature 36.4°C. He cannot tell you his name or where he is. A glucometer is available. Staff are reluctant to 'make a fuss' and suggest you 'let him sleep it off'.
1. Build a differential for this presentation and explain what you would do first and why.
Read the worked answer
Differential includes: hypoglycaemia (insulin, unknown last meal, alcohol - a classic and immediately reversible cause of confusion and aggression); alcohol intoxication; head injury (the forehead laceration and fall); stroke; sepsis or other infection; post-ictal state; and other metabolic causes.
The first action is a capillary blood glucose measurement. It is quick, non-invasive, and hypoglycaemia is common, dangerous and immediately treatable. Treating 'drunk' as a diagnosis without a glucose reading is a well-recognised cause of avoidable harm.
If hypoglycaemic, treat per protocol (oral glucose if able to swallow safely, or parenteral glucose per scope if not) and reassess. If not hypoglycaemic, the confusion plus the head injury and the fall means you must take the presentation seriously: assess for head injury, consider stroke, and do not accept the staff's suggestion to leave him.
The judgement tested is refusing to anchor on alcohol and insisting on objective measurement of reversible causes.
2. He is confused and pulling away. How do you balance his refusal and resistance against your duty to assess and treat, and what practical steps do you take?
Read the worked answer
- Capacity is decision-specific and time-specific. His confusion and inability to state his name or location raise real doubt about his capacity to refuse. A refusal from a patient who may lack capacity is not a valid informed refusal.
- Practical de-escalation: reduce stimulation, speak calmly and slowly, use his name if known, explain each step before doing it, keep movements predictable, and involve familiar staff. Give him space and time; do not crowd him.
- Assess in stages: start with the least intrusive observations (glucose, pulse, breathing) and build up. Use the minimum restraint necessary and only if immediately necessary to prevent harm; restraint is a last resort and must be justified and documented.
- Seek collateral information from staff and, if possible, family, and consider whether the confusion is fluctuating.
- If he continues to resist and you believe he lacks capacity and needs urgent care, escalate per local policy - this may involve seeking advice, involving a senior clinician, or the appropriate legal route for a patient lacking capacity. Document the capacity assessment, his responses, the steps taken and the rationale.
The professional theme is that duty of care and respect for autonomy are both real; the answer is careful, documented reasoning, not simply overriding him or simply walking away.
3. His glucose reads 2.1 mmol/L. He is drowsy but able to swallow. Describe your management and the reassessment points that determine your next step.
Read the worked answer
- Treat the hypoglycaemia promptly: if he can swallow safely and protect his airway, give oral glucose per protocol. If he cannot swallow safely or his conscious level falls, use parenteral glucose per your scope and protocol.
- Do not leave him: after treatment, reassess glucose, level of consciousness, airway and ability to swallow at intervals per protocol. Recovery can be rapid but can also recur, especially with long-acting insulin and no recent food.
- Once he is more alert, give a longer-acting carbohydrate if he can take it, and address the cause: when did he last eat, what insulin did he take, and is there anyone who can stay with him?
- Reassess the head injury once he is more orientated: the fall and confusion may have been caused by the hypoglycaemia, but a head injury could also have caused the fall. Ask about headache, vomiting, and any period of unresponsiveness, and check for focal signs.
- Decide on transport and handover: hypoglycaemia requiring treatment, with a head injury and an unreliable social situation, generally warrants transport and medical review. Communicate the glucose readings, treatment and response to the receiving team.
The judgement tested is that correcting the glucose is necessary but not sufficient - you must reassess, find the cause, and not miss the head injury.