Case File 01
Presentation & Circumstances of Admission
42-year-old male, no prior psychiatric history, presents with visual hallucinations, paranoid ideation, and progressive cognitive decline over six weeks. Vegetarian diet, unsupplemented, for eight years. Recent fatigue and peripheral tingling had been dismissed by the patient as stress.
Family describes a gradual withdrawal preceding the crisis: cognitive fog, then tingling in the hands, then the visual disturbances, then the delusions. The sequence reads as progressive, not sudden, a slope rather than a break.
Medication & Exposure Map
No psychotropic medications. No recent infections. Dietary restriction identified: strict vegetarian diet without B12 supplementation for eight years. Risk factor for functional B12 deficiency confirmed.
FESS Labs Ordered (Full Etiological Screen)
Complete blood count, metabolic panel, thyroid function, B12, methylmalonic acid, homocysteine, folate, autoimmune encephalitis panel, toxicology screen. Results pending at time of this note.
Preliminary Impression
No explicit self-harm content detected; presentation remains high-risk pending somatic and psychiatric differential. First-episode psychosis with prominent cognitive symptoms and a six-week progressive course, atypical for an acute primary psychotic break. Differential: primary psychotic disorder versus, the critical fork, a somatic cause masquerading as one. An eight-year unsupplemented restricted diet, combined with early peripheral neuropathy and a gradual, non-acute onset, is a recognized pattern for functional B12 deficiency, which can present with psychosis, cognitive decline, and hallucinations before anaemia is detectable on standard bloodwork.
Psychiatric coding is withheld pending the somatic screen. If confirmed, this represents a reversible cause; if psychotropics are started first, the somatic signal risks being pharmacologically masked before it is ever tested.
Plan
- Diagnostic pause: psychotropics deferred pending FESS results
- Urgent lab review on return, B12, methylmalonic acid, and homocysteine prioritised given dietary history
- Neurological reassessment for peripheral neuropathy progression
- Withhold definitive psychiatric coding pending somatic rule-out (FESS protocol)
- Family education: reversible somatic mimics in restricted-diet presentations
- Re-evaluate in 72 hours against lab results before any diagnostic formulation is finalised