L:\usmle review 7 - Sinoe medical homepage.

36. A man brings his 45-year-old wife to the emergency department. He states she has been ill
for 3 days and has been running a temperature of 99.8 to 100.5 F. Today she is having difficulty
staying awake, is talking to persons who are not there, and at times appears to be frightened of
something. She is restless and somewhat combative when restrained. What is the most likely
diagnosis
(A)
(B)
(C)
(D)
(E)
Acute stress disorder
Bipolar I disorder, manic type
Brief psychotic disorder
Delirium
Dementia
36. The correct answer is D. This is a psychotic level disorder (the patient is hallucinating). The
patient has a fluctuating level of consciousness and is disoriented. Also, there is a clear history of
a febrile condition that developed rather rapidly, all of which suggest delirium.
In acute stress disorder (choice A) a traumatic event occurs that precipitates an anxiety-type
reaction, not a change in the sensorium.
In both bipolar I disorder, manic type (choice B) and brief psychotic disorder (choice C), patients
may reach a level of behavioral disruption of psychotic proportion. They do not, however,
demonstrate changes in level of consciousness or major disorientation.
Persons with dementia (choice E) demonstrate a clear sensorium with no fluctuations in the level
of consciousness. In addition, persons with dementia predominantly show symptoms of
impairment of cognitive functions (e.g., memory impairment).