WBR591

Author	[[PageAuthor::Twinkle Singh, M.B.B.S. [1]]]
Exam Type	USMLE Step 2CK
Main Category	Behavioral Science/Psychiatry
Sub Category	Psychiatry
Prompt	A 35 year old man presented with right upper quadrant abdominal pain. Initial ultrasound confirmed the presence of gall stones and an elective cholecystectomy was performed. Post operatively he is stable with vitals BP 130/90, Pulse 100/min and RR 18/min, but complains of tremulousness, increasing anxiety and “bugs crawling on his hands”. On examination patient is confused and tremors are noted in both hands. Rest of the neurological examination is within normal limits. What is the most common cause of his present complaints?
Answer A	Cocaine intoxication
Answer A Explanation	Cocaine intoxication can present with tactile hallucinations and anxiety, however, tremors and hallucinations in a hospital setting is more specific for substance withdrawal than intoxication.
Answer B	Brief psychotic disorder
Answer B Explanation	Brief psychotic disorder is defined as presence of at least 2 of the 5 symptoms which define schizophrenia for more than one day and less than one month in absence of any other condition. Symptoms which define schizophrenia are: hallucinations, delusions, disorganized thought (speech), disorganized or abnormal motor behaviour (including catatonia), and negative symptoms. Presence of auditory hallucinations is more common than visual hallucinations in schizophrenia.
Answer C	Schizophrenia
Answer C Explanation	For diagnosis of schizophrenia, symptoms must be present for more than 6 months. If symptoms are present for more than one month but remits within six months, it is classified as schizophreniform disorder
Answer D	Alcohol withdrawal
Answer D Explanation	Alcohol withdrawal is the most probable reason for tremors and visual hallucinations in a hospital setting. Most commonly patient presents with these symptoms one day after admission
Answer E	Post operative delirium
Answer E Explanation	Post operative delirium is more commonly present in elderly patients. It manifests with agitation and a fluctuating level of consciousness. It is caused by wide range of etiologies such as infections, drugs, electrolyte disturbance, post operative pain, hypotension and dehydration. It is a diagnosis of exclusion, therefore a meticulous search for etiology is mandatory.
Right Answer	D
Explanation	Mild to moderate alcohol withdrawal manifests as autonomic hyperactivity, insomnia, tremulousness, anxiety, sweating, hypertension, tachycardia and fever. Patients with chronic alcohol use can also present with hallucinations. Visual hallucinations are more common, but auditory and tactile hallucination can also be present. Severe alcohol withdrawal manifests with seizures and delirium tremens. Delirium tremens usually occurs after 2-4 days of alcohol abstinence. Educational Objective: References:
Approved	No
Keyword	Alcohol withdrawal
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