Question

Please Write Succinct:   Delirium on a 80 yr old patient

• Review of Systems: Associated symptoms and Risk Factors
• Findings on Focused Physical Exa
• Five Differential Diagnosis

See example below for question #1:

1. Sore Throat

ROS:

Associated symptoms: fever, redness or eye discomfort, sneezing, wheezing, cough, runny nose, postnasal drip, GERD like symptoms, fatigue, muscle ache, n/v, and diarrhea.

Risk Factors:

Smoking, new sexual partners, irritant exposure, medications, and chronic health problems.

Red flags:

drooling, unable to swallow, unable to lie down, restless, unable to stay still, and unable to talk.

PE findings:

Epiglottis- severe illness with signs of upper airway obstruction such as restlessness, stridor, difficulty breathing, drooling, inability to swallow and high fever signals epiglottis and requires immediate referral. Further examination with a tongue blade could trigger laryngospasms and lead to airway obstruction.

Peritonsillar retropharyngeal abscess- orthopnea, dyspnea, symmetrical swelling, abscess, trismus.

Viral pharyngitis: Erythema, edema of throat, tender posterior cervical nodes.

GAS: temp more than 101.5, exudate anterior cervical lymphadenopathy.

Mononucleosis: presence or absence of pharyngeal exudate, posterior cervical lymphadenopathy, splenomegaly.

Gonococcal pharyngitis: pharyngeal exudate bilateral cervical lymphadenopathy

Inflammation: sinus tenderness, pale or swollen pharynx, postnasal drainage visible, no fever or lymphadenopathy.

Aphthous Stomatitis: shallow ulcers, no vesicles; indurated papules that progress to 1 cm ulcers; ulcer has yellow membrane and red halo; no fever or nodes.

Herpes simplex Lesions: perioral lesions; lymph adenitis; vesicles on palate, pharynx gingiva.

Herpetic pharyngitis: vesicles, ulcers, or exudate of the oral and pharyngeal mucosa.

Candidiasis: curd like white plaques that bleed when scraped off.

Differential diagnosis:

Viral Pharyngitis, Streptococcal Pharyngitis, peritonsillar or retropharyngeal abscess, Mononucleosis, Epiglottis, gonococcal pharyngitis, Herpangina, Vincent angina, Aphthous stomatitis, HSV type 1, Candidiasis, GERD.

Answer 1

Delirium is a state of sudden severe confusion that may occur with physical or mentall illness. It is a reversible condition especially seen in older adults.

Associated symptoms:

• Reduced awareness of environment such as showing inability to stay on a single subject or switching of topics.
• Cognitive impairment such as poor memory, disoriented speech
• Hallucinations
• Behavioral changes such as restlessness, agitation
• Emotional disturbances such as anxiety, fear, anger, depression

Risk factors:

• Alcohol withdrawal or drug overdose
• Electrolyte imbalance
• Lack of sleep
• Poison
• General anesthesia or surgery
• Infections such as intracranial infections, Pneumonia

Redflags:

• In hypoactive delirium patient will be quiet,withdrawn, apathetic and drowsy
• In hyperactive delirium patient will be aggressive, agitated and refuse to co operate
• In Mixed delirium patient will show both symptoms of hypoactive and hyperactive delirium.

Physcial examinations

• Inspect skin for the evidence of any trauma

Mental status examination

• Attention: patient will be distracted early, wandering of topics and provide trivial informations
• Memory: Patient will have difficulty in receiving recent memories and deliver new memories
• Disoriented to place and time: Patent will be confused about the date, time, day and place
• Calculation impairment: Patient will show difficulty in doing calculations that require concentrations
• Hallucinations and delusions: Patient will have visual and auditory hallucinations. Patient will not be concerned or even deny being ill.
• Alteration in sleep wake cycle: Sleep deprivation will be there and patient will be restless or agitated during evening or at dark light.
• Mood change: Fluctuation in moods between elevated and depressed will be there

Differential diagnosis:

• Psychiatric disorders such as schizophrenia, Bipolar disorders
• Acute stress disorder such as fear and anxiety
• Neurocognitive disorders such as dementia
• Confusional state.