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  #1  
Old 10-25-2012
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Question Confused and Febrile 74 Yr Old Man

A 74-year-old man is brought to the emergency department after he became combative and was screaming that "the little people" were after him. The staff is unable to obtain a history or physical examination because of his agitation, although the triage nurse is able to obtain his vital signs, which are significant for a temperature of 40 C (104 F) and a blood pressure of 90/50 mm Hg. His family reports that he was fine earlier in the day except for an occasional cough, and that he has never had any psychiatric issues before. By the time the psychiatrist arrives, the patient is somnolent and somewhat confused. Which of the following will confirm this patient's most likely diagnosis?


A Blood alcohol level
B Blood, urine, and sputum cultures
C CT of the head
D Electroencephalography
E Urine toxicology screen
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Old 10-25-2012
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Urine toxicology screen ??
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Old 10-25-2012
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I would choose B) Blood, urine and sputum cultures. I think the man in the stem questions has pneumonia with Legionella, because he has high fever, cough and confusion, due to hyponatremia that usually associates with Legionella.
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  #4  
Old 10-25-2012
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Default BB..delirium

BB..pxt is having Delirium. common causes of delirium especially in the elderly are UTI, infection & antimuscarinics which can be diagnosed from option B
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Old 10-25-2012
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Default my answer B

Ruling out septicemia.....
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Old 10-25-2012
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have no idea....
but @teona answered very reasonably...so, B could be the right one by exclusion.......

thanks
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Old 10-25-2012
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Urine toxicology or culture everything but culture slow so will go with E But can't associate with any infection if it's legionella than back to micro
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Default my answer :)

B Blood, urine, and sputum cultures - sepsis leading to confusion?
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  #9  
Old 10-26-2012
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I would go with D. I'm thinking it's delirium=acute onset=abnormal EEG would differentiate. That's what I think..
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Default DD... EEG is diagnostic

Quote:
Originally Posted by blade View Post
BB..pxt is having Delirium.common causes of delirium especially in the elderly are UTI,infection & antimuscarinics which can be diagnosed from option B
Agreed with Dockhi.
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Old 10-26-2012
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Quote:
Originally Posted by MedicalExaminer View Post
A 74-year-old man is brought to the emergency department after he became combative and was screaming that "the little people" were after him. The staff is unable to obtain a history or physical examination because of his agitation, although the triage nurse is able to obtain his vital signs, which are significant for a temperature of 40 C (104 F) and a blood pressure of 90/50 mm Hg. His family reports that he was fine earlier in the day except for an occasional cough, and that he has never had any psychiatric issues before. By the time the psychiatrist arrives, the patient is somnolent and somewhat confused. Which of the following will confirm this patient's most likely diagnosis?


A Blood alcohol level
B Blood, urine, and sputum cultures
C CT of the head
D Electroencephalography
E Urine toxicology screen
fever, cough- indicate more of an infectious cause then alcohol or substance abuse.
So will go with B.Blood, urine, and sputum cultures
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Old 10-27-2012
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Answer plz ??
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my apologies
totally forgot about that

The correct answer is B. This patient is experiencing delirium, which is characterized by a decreased attention span and level of arousal, disorganized thinking, hallucinations, illusions, misperceptions, disturbance in sleep-wake cycle, fluctuating levels of consciousness, and cognitive dysfunction. Delirium is the most common psychiatric diagnosis on medical and surgical floors, particularly among elderly patients. Delirium may be caused by infection, metabolic disturbances, electrolyte abnormalities, hypoperfusion, drug intoxication, alcohol intoxication or withdrawal, and adverse effects due to medication. In this patient, the combination of a high fever and hypotension suggests an infectious etiology. The causative agent is likely to be identified through blood, urine, and sputum cultures.

Answer A is incorrect. A blood alcohol level will give the physician insight into the presence of alcohol intoxication or withdrawal, both of which can cause delirium. In this patient, however, infection is the more likely cause given his fever.

Answer C is incorrect. CT of the head can detect the presence of structural brain abnormalities, hematomas, hemorrhages, infarcts, and masses. Although these processes can certainly lead to changes in mental status, this patient is presenting with clear signs of delirium most likely related to an infection. CT of the head is unlikely to be useful in this setting.

Answer D is incorrect. An electroencephalogram is useful in documenting a seizure or the postictal state following a seizure. While complex partial seizures can be associated with hostile, aggressive behavior, they are also typically associated with automatisms such as lip-smacking and grimacing, which this patient is not experiencing.

Answer E is incorrect. A urine toxicology screen will detect the presence of metabolites of recently ingested drugs. While drug intoxication is a well-established cause of delirium, infection is the more likely cause in this patient given his high fever. However, in delirious patients in whom the cause is not obvious, it is crucial to perform toxicology screens of the urine and blood.
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i think its a uw question but i confused between b and e may be its b
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i think its a uw question but i confused between b and e may be its b
questions are from
First Aid Q&A for the USMLE Step 1,
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  #16  
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questions are from
First Aid Q&A for the USMLE Step 1,
@medicalExaminer
thanx for question..this px is delirious right.and the question is to confirm diagnosis of delirium not the primary cause of dx.
EEG changes is seen in delirium(option D)while option B can hit the primary cause of dx?????

i wonder why they shld include 2 very related options
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Quote:
Originally Posted by blade View Post
@medicalExaminer
thanx for question..this px is delirious right.and the question is to confirm diagnosis of delirium not the primary cause of dx.
EEG changes is seen in delirium(option D)while option B can hit the primary cause of dx?????

i wonder why they shld include 2 very related options
thats the goal of the test to confuse and mix up ur mind
u have to choose the best from related options
i personaly would consider urine toxicology too (if appropriate age brackets)
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