Section: USMLE

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?

1. Acute stress disorder
2. Bipolar I disorder, manic type
3. Brief psychotic disorder
4. Delirium
5. Dementia

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 a traumatic event occurs that precipitates an anxiety-type reaction, not a change in the sensorium.

In both bipolar I disorder, manic type and brief psychotic disorder, 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 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).