An 82-year-old woman is admitted to the ED short stay ward

overnight for observation. She presented with a generalised urticarial rash

with lip swelling after eating her Christmas lunch at home with her family. She

was given adrenaline 0.3mg IM on arrival at 8pm. Prednisone 50mg was given 15

mins later together with promethazine oral.

She is normally well, lives alone and independent in all her

daily activities. She lives close to her children and grandchildren. She has no

cognitive impairment noted in her eMR. She is on aspirin 100mg daily and

lercandipine 10mg at night for her hypertension.

This morning, she is confused and unable to attend to her

toileting and has been incontinent. HR

90/min, BP 140/90 mm Hg, temp 37°C.

Her vital signs are normal.

What is the most likely cause of her symptoms?

A 75-year-old man is admitted under the Infectious Disease

unit with Covid. However, he is in the ED due to a lack of isolation beds. You

are called to his isolation room. He is yelling and pulling at his monitoring

leads. The nurse is unsuccessful in calming him. He has now required 4 other

nursing staff to hold him to prevent him from falling. The emergency buzzer for

the room has been pressed.

Question:

The patient above had a lumbar puncture performed as part of the workup investigations for his delirium. The patient's investigations have returned.

CSF results:

Question: What is your interpretation of his CSF results?

For this patient, you are

looking for the underlying causes of his delirium. There is no further

information you can obtain from his flatmate, GP or language school. There are

no relatives to contact.

You are about to order some pathology tests. Which of the

following list of electrolyte abnormalities may cause delirium?

A 25-year-old man is brought in from the Language School due

to abnormal behaviour. His tutor noted that he was behaving oddly - distracted

in class, confused and disorientated to time, place, and person.

On examination, you find it hard to engage him. He is not fluent in English. You cannot

complete a neurological examination due to his inattention. He can focus on you

and others but only for a short period of time. He has no evidence of auditory

or visual hallucinations.

His vital signs: HR 78 bpm, BP 110/70 mmHg, temp 37°C, BSL 5.5 mmol/L.

What is your differential diagnosis at this stage?

For this 25-year-old language student, you are looking for

the underlying causes of his delirium. You have contacted his flatmate who says

that he has been unwell for the last 4 days. He has found a bag of prescribed

medications in his room. His medications are: paracetamol, ibuprofen,

promethazine, ondansetron, mouthwash.

Which of the following may cause delirium?

The patient above has now settled into your acute bed in the

ED. Under observation, you note that he seems withdrawn and mute. However,

after a period of 2 hours, you are called to the bedside by the nurses. He is

pacing, shaking and looking anxious. He refuses to return to bed and is

requiring 2 nurses to hold onto  him.

They have repeated his observations. HR 90/min, BP 130/80, RR 18, SAO2 96% and

Temp: 36.8°C.

They are concerned that he is unsafe without one-on-one

nursing.

Question:

Which of the following medications used in elderly people has the least propensity to induce delirium?

A 40-year-old man presents with acute confusion. He is disorientated to time, place, and person and you are having trouble getting a history from him. You have access to his past history from the electronic medical records (eMR). From the eMR, you identified the following information. Which of the following is likely to be a cause of his acute confusion?

An 85-year-old man presents to the ED with acute confusion. He has atrial fibrillation and chronic back pain. You review his medications during your assessment. Which of the medications should be stopped as it may be contributing to his acute confusion?