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Mr. Thompkins is an otherwise healthy 72-year-old man who was admitted after experiencing 15% total body surface area burns to his trunk, arms, neck, and face. He is now 2 days s/p excision and grafting of his injuries. His postoperative course was unremarkable until last evening when he became acutely confused. He stated that he was at the library and he was observed to be having conversations with people who were not there. The patient also began to pull at his lines and attempted to get out of bed. He required frequent redirection and reorienting by his nurse, which prompted a call to the night float resident. The nurse was particularly concerned that he may be in alcohol withdrawal as it was reported in his admission note that he consumed ethanol in “social situations.”

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The night float resident initially gave the patient lorazepam 2 mg IV to sedate him. He was then placed on lorazepam 1 mg IV every 4 hours standing, along with PRN lorazepam ordered “per signs of alcohol withdrawal.” Despite these interventions the patient’s mental status continued to worsen, and on rounds the following morning your team discovers that he now requires oxygen supplementation. You review the rest of his medications and note that the patient is also on a hydromorphone PCA, which the nurse tells you she has been activating “to keep him comfortable” as the patient is too confused to use the PCA himself.

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On physical examination, his vitals are T: 99.9, HR: 115, BP: 150/90, R: 16, and O2: 97% on 3 L of oxygen per nasal cannula. The patient is lying in bed with his eyes closed, although he can be aroused with loud verbal stimuli. He is oriented only to self and falls asleep repeatedly during the examination. When he is awake, he has difficulty maintaining focus and attention. Pupils are equal and reactive, and his cranial nerve examination is intact. Upper extremities are without cogwheeling, rigidity, or tremor. The patient displays a palmomental reflex bilaterally; however, no glabellar, snout, or plantar reflexes are noted. In addition, there are intermittent myoclonic jerks of the upper extremities and trunk.

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Laboratory results are notable only for a WBC of 16,700 and a sodium of 129. A review of admission labs includes a normal MCV of 95, an ALT of 22, an AST of 28, and normal coagulation studies. A blood alcohol level along with a urine toxicology screen at the time of admission was negative.

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1. Based on the details given, does this patient meet the diagnostic criteria of delirium?

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2. Is delirium life-threatening?

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Altered Mental Status

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Answers
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  1. In assessing mental status changes in the hospitalized patient it is important to distinguish delirium from other underlying psychiatric disorders. Delirium, as opposed to most other ...

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