Psychiatry question

[LuckiestOne]

---

Members don't see this ad.

A 20-year-old man is brought to the emergency
department with frightening visual hallucinations.
He is confused, disoriented to time and place, and
difficult to understand because of slurred speech.
Which of the following is the most likely diagnosis?

(A) Brief reactive psychosis
(B) Delirium
(C) Mania
(D) Psychotic depression
(E) Schizophrenia

What do you guys think the answer is and please provide an explanation.

Thanks!

 

[Phloston]

A 20-year-old man is brought to the emergency
department with frightening visual hallucinations.
He is confused, disoriented to time and place, and
difficult to understand because of slurred speech.
Which of the following is the most likely diagnosis?

(A) Brief reactive psychosis
(B) Delirium
(C) Mania
(D) Psychotic depression
(E) Schizophrenia

What do you guys think the answer is and please provide an explanation.

Thanks!

A bit vague of a question, but C, D and E can all be eliminated because they notably are out of context.

Between A and B, we'd want evidence of a physical process (e.g. fever, drugs) in order to diagnose delirium.

I've heard of altered speech occurring with brief reactive psychosis, and the fact that he's having hallucinations also supports that. Hallucinations need not be a component of delirium.

So I'd say choice A.

 

[LuckiestOne]

yeah, this question was REALLY vague. I will wait for few more replies so more people can put in their .02

Thanks Phloston

 

[LuckiestOne]

Since no one seems to be interested in the question I will post the answer... The answer given was Delirium. Now what the hell, how are we supposed to explain this? I picked A as well and got it wrong

 

[Myxedema]

Since no one seems to be interested in the question I will post the answer... The answer given was Delirium. Now what the hell, how are we supposed to explain this? I picked A as well and got it wrong

There's nothing there to differentiate between those two. The question is way too vague.

 

[chaotic mind]

Since no one seems to be interested in the question I will post the answer... The answer given was Delirium. Now what the hell, how are we supposed to explain this? I picked A as well and got it wrong

Disorientated in time and place would point towards delirium.
I would have picked A otherwise.but now that the answer is there delirium seems correct.

 

[mmmcdowe]

A bit vague of a question, but C, D and E can all be eliminated because they notably are out of context.

Between A and B, we'd want evidence of a physical process (e.g. fever, drugs) in order to diagnose delirium.

I've heard of altered speech occurring with brief reactive psychosis, and the fact that he's having hallucinations also supports that. Hallucinations need not be a component of delirium.

So I'd say choice A.

Sure, but I think in terms of the step one this is pushing it. My impression of step 1 from taking it and tutoring is that brief reactive psychosis is essentially limited to psychotic symptoms, regardless of the real world scenario. Also, psychosis doesn't to me bring in mind "confused". They are quite confident in their psychoses in many cases. Confused, plus slurred, plus crazy brought to mind delerium from a substance or from withdrawal.

 

[Phloston]

Lol nice. This question is the common-type you get in GT QBank (http://forums.studentdoctor.net/showthread.php?t=929668). Most of them are pretty vague, but occasionally you get one that teaches you something new.

 

[glykon]

Lol nice. This question is the common-type you get in GT QBank (http://forums.studentdoctor.net/showthread.php?t=929668). Most of them are pretty vague, but occasionally you get one that teaches you something new.

Hallucinations are frequently found in pts. with delirium. Actually, this pt. had delirium a la carte 🙂

 

[Boardz]

A 20-year-old man is brought to the emergency
department with frightening visual hallucinations.
He is confused, disoriented to time and place, and
difficult to understand because of slurred speech.
Which of the following is the most likely diagnosis?

(A) Brief reactive psychosis
(B) Delirium
(C) Mania
(D) Psychotic depression
(E) Schizophrenia

What do you guys think the answer is and please provide an explanation.

Thanks!

this was actually a super-easy question. if you didn't get it, you should seriously study behavioral science more. I'm not trying to be mean or whatever. But you can't do well on the boards if you can't answer gimme behavioral science questions. With this question, for starters, just look up the _definition_ of delirium. good luck.

 

[Zenfudge]

In addition to the altered state of consciousness suggesting delirium, presence of visual hallucinations is telling (though still pretty vague).

We were told in our psychiatry clerkship to suspect malingering or some other process if a schizophrenic or bipolar patient endorsed visual hallucinations. Hallucinations are almost always auditory, and almost always omnidirectional (patient can't tell you where they are coming from). Visual hallucinations in delirium and of course delirium tremens are very common, however. I would have chucked C,D,E for not meeting criteria. Getting rid of A is harder though.

On my actual step 1 you had to differentiate between a psychotic schizophrenic patient and a psychotic manic patient by history (and they didn't give you buzzwords like "decreased need for sleep" either). I could see a question like this popping up, but the stem would probably be much longer and you'd more likely be parsing out delirium vs. dementia. I'd always ask myself: Does this patient's consciousness seem altered?

Also, once you see a delirious patient in the hospital, this question is easier. The patient will think that there are people outside their room trying to shoot them with bows and arrows and then they'll drift off back to sleep (true story). Totally sane person with ICU psychosis, i.e. delirium.

 

[LuckiestOne]

In addition to the altered state of consciousness suggesting delirium, presence of visual hallucinations is telling (though still pretty vague).

We were told in our psychiatry clerkship to suspect malingering or some other process if a schizophrenic or bipolar patient endorsed visual hallucinations. Hallucinations are almost always auditory, and almost always omnidirectional (patient can't tell you where they are coming from). Visual hallucinations in delirium and of course delirium tremens are very common, however. I would have chucked C,D,E for not meeting criteria. Getting rid of A is harder though.

On my actual step 1 you had to differentiate between a psychotic schizophrenic patient and a psychotic manic patient by history (and they didn't give you buzzwords like "decreased need for sleep" either). I could see a question like this popping up, but the stem would probably be much longer and you'd more likely be parsing out delirium vs. dementia. I'd always ask myself: Does this patient's consciousness seem altered?

Also, once you see a delirious patient in the hospital, this question is easier. The patient will think that there are people outside their room trying to shoot them with bows and arrows and then they'll drift off back to sleep (true story). Totally sane person with ICU psychosis, i.e. delirium.

Thank you for your insight, appreciate it!

 

[Phloston]

I would say that even if delirium is the answer, it is not the most likely diagnosis because we would need evidence of a physical process before considering it. The vignette gives no mention of that whatsoever. Therefore, for one to arrive at delirium as the "most likely diagnosis," he or she would be overlooking the criteria entirely. Nevertheless, I would doubt that a question this vauge would ever show up on the real USMLE.

I've also noticed Boardz' tendency toward derogatory remarks.

 

[Belleza156]

A 20-year-old man is brought to the emergency
department with frightening visual hallucinations.
He is confused, disoriented to time and place, and
difficult to understand because of slurred speech.
Which of the following is the most likely diagnosis?

(A) Brief reactive psychosis
(B) Delirium
(C) Mania
(D) Psychotic depression
(E) Schizophrenia

What do you guys think the answer is and please provide an explanation.

Thanks!

I'd go with brief reactive psychosis, sounds like he's on PCP.

Sent from my PC36100 using SDN Mobile

 

[Belleza156]

I'd go with brief reactive psychosis, sounds like he's on PCP.

Maybe that particular question wanted you to answer delerium, but a question like this on the real thing wants you to answer that its associated w a drug. Anyways don't worry about this obscure question, a question on step 1 will be straight forward and youll know if they want you to answer delerium or psychosis. There won't be any confusion. Just make sure you memorize all withdrawal symptoms and can be able to differentiate them from substance intake. Learn everything in FA, and then expand. You need to know how ppl present who have lead poisoning, arsenic poisoning, sniff glue, sniff paint cans, PCP, LSD, ecstasy, cocaine, weed, and whatever else ppl do that's common. Know how they present when high, and know how they present when coming down. And especially know which drugs do not have a withdrawal, they always try to trick you w that.

I prob got 4 questions on this topic. All straightforward.

Sent from my PC36100 using SDN Mobile

Sent from my PC36100 using SDN Mobile

 

[Boardz]

I would say that even if delirium is the answer, it is not the most likely diagnosis because we would need evidence of a physical process before considering it. The vignette gives no mention of that whatsoever. Therefore, for one to arrive at delirium as the "most likely diagnosis," he or she would be overlooking the criteria entirely. Nevertheless, I would doubt that a question this vauge would ever show up on the real USMLE.

I've also noticed Boardz' tendency toward derogatory remarks.

Just being 100% honest. Delirium is super high-yield. If you're spending too much time learning about rette's disorder and other stuff before mastering a high-yield concept like delirium- no matter if you've done 20,000 q's by now, you're doing it wrong.

 

[Boardz]

A 20-year-old man is brought to the emergency
department with frightening visual hallucinations.
He is confused, disoriented to time and place, and
difficult to understand because of slurred speech.
Which of the following is the most likely diagnosis?

(A) Brief reactive psychosis
(B) Delirium
(C) Mania
(D) Psychotic depression
(E) Schizophrenia

What do you guys think the answer is and please provide an explanation.

Thanks!

from a book:

The onset of delirium is usually acute and is marked by an altered state of consciousness with a fluctuating course. The patient will almost always present with deficits in attention, concentration, and memory; they will appear disoriented and hallucinations, behavioral disinhibition, irritability, psychomotor slowness or hyperactivity, and other psychomotor deficits such as slurred speech. Delirium is often caused by metabolic disturbances, medications, or infections and is usually reversible with correction of the underlying etiology.

Delirium can be differentiated from other disorders by its rapid onset and the presence of disorientation and confusion. Psychotic disorders such as schizophrenia and brief reactive psychosis, or mood disorders such as psychotic depression and mania, can be accompanied by delusions or hallucinations. But none of these disorders (despite how abnormal the patient's behavior might be) present with disorientation to time or place, confusion, or slurred speech as seen in delirium. However, other abnormalities in speech (disorganized or pressured) and behavior may be present in these disorders.

 

[Boardz]

A bit vague of a question, but C, D and E can all be eliminated because they notably are out of context.

Between A and B, we'd want evidence of a physical process (e.g. fever, drugs) in order to diagnose delirium.

I've heard of altered speech occurring with brief reactive psychosis, and the fact that he's having hallucinations also supports that. Hallucinations need not be a component of delirium.

So I'd say choice A.

ps this is from nbme 1 so adjust your score accordingly when you take it.

 

[Belleza156]

Also keep in mind when you do they older NBMEs that a lot of the questions are no longer valid and that's why they removed the NBME. I can tell you for a fact that hardcopy NBME 1 that is available if your school pays for it is not the same as the one that floats around the web.

If you ever encounter a question in the older NBMEs that conflicts with what the current answer would be in Uworld/Kaplan then x out that question.

Rule of thumb #1: Uworld before Kaplan, Uworld and Kaplan before all NBMEs prior to NBME 7.

Rule of thumb #2: NBME 7,11,12,13 before Uworld, U world before Kaplan.

You will find questions where the more recent NBMEs conflict slightly with Uworld, and you will want to answer on Step 1 what the NBME had as correct, because that is the answer that is still in their question bank (always pay for extended score report, and jot down the answers you put for every question, that way you can go thru the pdf files and know which are correct and which are incorrect, without any uncertainty).

 

[Phloston]

Great input. Helpful as always, Belleza.

And, boardz, the second to last sentence of what you've posted is also very helpful.