delirium

Question 1

Q1: Mr. B is a 54 y.o. surgical in-patient who had an emergency operation 2 days ago following perforation of a duodenal ulcer.

at 2am, you are called by the night staff who report that he is very agitated, confused and trying to leave the ward.

they also tell you that he lives alone and has no close relatives.

you think that delirium (acute confusional state) is an important dx to consider.

(a) suggest 3 psychiatric sx/signs you would look for, either from the above presentation or from further assessment, to confirm your dx

Answer 1

1. reversal of sleep/wake pattern
2. disturbance of cognition
3. emotional changes
4. visual/auditory hallucinations
5. delusions
6. loss of insight (disorientation)

Question 2

(b) list 4 possible predisposing causes which could have precipitated this attack of delirium

Answer 2

recent surgery,

• ↑ risk of infection
• ↑ risk of vascular event
• ↑ risk of metabolic imbalance
• post-op opioids

Question 3

(c) list 3 cognitive fx you would like to test and give an example of one question for each fx

Answer 3

1. Orientation to Time, Place and Person
2. Recall e.g. list 3 unconnected objects and ask pt to repeat back immediately then later (delayed recall)
3. Language i.e. name an object e.g. pen

Question 4

Q2: 74 y.o. woman admitted to hospital having collapsed at home. her daughter tells you she has been drowsy for the past couple of days and has a cough productive of green sputum. she smokes 20 cigarettes per day. O/E she is centrally cyanosed and you find her temp to be 39.5˚C. her PR is 120 and BP 130/80. she’s noticed to be choking on food. she has no ankle oedema. she is restless and vague about recent events and has abbreviated mental score of 6/10.

(a) what is the dx of this lady’s acute deterioration in mental dysfunction?

Answer 4

delirium

Question 5

(b) give 2 possible causes of this lady’s deteriorating mental fx

Answer 5

1. infection (e.g. pneumonia)
2. hypoxia
3. cerebrovascular accident

Question 6

(c) you undertake an ABG estimation. what 2 blood gas abnormalities would you predict that would relate to the above condition?

Answer 6

1. hypoxia
2. acidosis

Question 7

(d) how would you try to correct these gas abnormalities and what precautions should you take?

Answer 7

oxygen therapy

use low flow i.e. 24% venturi mask due to risk of COPD in this pt

Question 8

(e)(i) list 2 abx that would be most appropriate for rx of the underlying condition

(ii) how would these best be administered given the present situation?

Answer 8

(i) amoxicillin, clarithromycin
(ii) intravenous

Question 9

(f) 12 hours following admission, the staff nurse tells you that Mrs Smith has not passed urine.

what would be the most appropriate ix and how would you correct this abnormality?

Answer 9

investigation → U+Es or pelvic USS

urinary catheter