Vignette Analysis: Delirium Tremens (DT), Alzheimer’s Disease, Dementia
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Vignette Analysis: Delirium Tremens (DT), Alzheimer’s Disease, Dementia
The diagnosis of Maria’s condition is Delirium Tremens. This is based on the symptoms of memory difficulties and tremor. The low vitamin B levels, calcium hypertension and anxiety are all attributable to alcohol withdrawal. The condition is characterized by acute psychosis following abstinence from alcohol in chronic alcoholics as seen in this case. Any rapid decline in the intake of alcohol could have resulted to the condition. Maria is also reported to take some medications for anxiety. Coarse tremor acid reflux and visual, tactile and auditory hallucinations are also attributable to Delirium Tremens. Onset of DT is usually between two to five days of abstinence, but it might occasionally take up to 7 days to manifest (Mehta et al., 2011).
The steps to take in differential diagnosis
To differentiate the condition from other mental conditions such as Parkinsonism, Alzheimer’s disease and dementia several tests and analysis of the patient history need to be conducted. Obtaining a detailed social and medical history of the patient will be important so as to directly associate the condition to alcohol withdrawal or decrease in amount. This will eliminate probability of such conditions as Alzheimer’s disease and Dementia which are rarely caused by alcohol withdrawal. A computed tomography (CT) scan of Maria’s brain will distinguish the condition from other neurodegenerative disorders such as Alzheimer’s disease and dementia. For instance, a CT scan of an Alzheimer’s disease patient would show amyloid precursor cells which are not expected to be present in this patient (Baquero & Nuria, 2015).
Response to heavy doses of vitamin B complex. The patient will be expected to show good recovery with heavy doses of intravenous vitamin B complex, glucose and oral benzodiazepine. Alcohol interferes with vitamin B 12 absorption which will be expected to Maria who has a long history of alcoholism. Patients with Alzheimer’s disease also have low levels of vitamin B12 but do not show recovery with administration of the vitamin. In addition, the liver function tests can also be used to differentiate this health condition from others. Altered hepatic biochemical parameters are concordant with alcoholism. Consecutively, tests are done to rule out other associated problems such as electrolyte abnormalities, pancreatitis, and alcoholic hepatitis. Thyroid function test should also be performed to rule out thyrotoxicosis.
The additional evaluations that I would require
The history and physical examination will be evaluated to establish the diagnosis and severity of alcohol withdrawal. I would also inquest for important historical data include quantity of alcoholic intake, duration of alcohol use, duration since last alcoholic drink was taken, previous alcohol withdrawals or reductions, presence of concurrent medical or psychiatric conditions, and abuse of other agents (Smith et al., 2004). In addition to identification of withdrawal symptoms, thorough physical examination should be performed to assess possible complicating medical conditions, such as cardiac arrhythmias, congestive heart failure, coronary artery disease, gastrointestinal bleeding, infections, liver diseases, nervous system impairment, and pancreatitis. Basic laboratory investigations including a complete blood count, liver function tests, a urine drug screen, and determination of blood alcohol and electrolyte levels (Baquero & Nuria, 2015). Liver function tests aid in assessment of cirrhosis, hepatitis and other alcohol induced liver illnesses. It would also be necessary to conduct analysis of serum electrolytes to check alcohol-induced acidosis. Also evaluate for the severity of the symptoms to identify the severity of the condition. Additional symptoms that should be assessed include including headache, orientation, paroxysmal sweating, visual disturbances, nausea and vomiting, hallucinations and agitations.
Evaluation of Maria’s mental status
Maria is reported to have poor mental status and anxiety. She reportedly takes medications for anxiety. The evaluation of her mental status will be based on ten items by the Clinical Institute Withdrawal Assessment for Alcohol. This is to quantify the severity of her withdrawal as mild, moderate or severe withdrawal or delirium tremens. The delirious individual may be evaluated for emotional disturbances, such as anxiety, fear, depression, irritability, anger, euphoria, and apathy (Smith et al., 2004). There may be affective lability, with rapid and unpredictable shifts from one emotional state to another
The information on diagnosis to be shared with the patient’s children
The physician-patient relationship is very important to both the patient and the physician and is largely influenced by the patient’s family. The patient’s family members play a crucial role in giving an accurate diagnosis as they provide vital information to the physician. This provides a good plan for treatment strategy during the office visit (Stern et al., 2010). It is, however, important for the physician to keep an appropriate balance when addressing concerns to maintain the alliance formed among physician, patient, and family member. The physician should apply his understanding of ethics and professional codes to avoid misuse of information.
The information I would give to Maria’s children about the diagnosis would include informing them the nature of the condition in the modest language. I would also report on the risk factors so that they assist in giving the necessary psychological support to the mother (Smith et al., 2004). In reporting the diagnosis, I would remain positive. The children would also require getting some information about the treatment plan and adherence (Stern et al., 2010). I would also give a prognosis, if positive. While giving this information, I would best navigate the demands of this encounter by maintaining a primary focus on the patient’s needs.
Baquero M., & Nuria M., (2015). Depressive symptoms in neurodegenerative diseases. World J Clin Cases. 2015 Aug 16; 3(8): 682–693. Published online 2015 Aug 16. doi: 10.12998/wjcc.v3.i8.682
Mehta S., Prabhu H., Swamy A., Dhaliwal H., and Prasad D., (2011). Delirium Tremens. Med J Armed Forces India. 2004 Jan; 60(1): 25–27. Published online 2011 Jul 21. doi: 10.1016/S0377-1237(04)80152-7
Smith M., Beecher L., Fischer T., Gorelick D., Guillaume J., Hill A., Jalla G., Kasser C., and Melbourne J., (2004). Management of Alcohol Withdrawal Delirium. Retrieved from, https://www.csam-asam.org/sites/default/files/pdf/misc/delirium_guidelines_ARCH_IM.pdf
Stern T., Gross A., Nejad S., and Maldonado J., (2010). Current Approaches to the Recognition and Treatment of Alcohol Withdrawal and Delirium Tremens: “Old Wine in New Bottles” or “New Wine in Old Bottles” Prim Care Companion J Clin Psychiatry. 2010; 12(3): PCC.10r00991. doi: 10.4088/PCC.10r00991ecr
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