Confusion / Delirium OSCE - Delirium Tremens | Free OSCE Practice

Case Overview

Age/Sex: 46-year-old male
Occupation: IT support (sedentary job)
Setting: Brought to the emergency department by his wife
Chief complaint: "He's confused and not himself"

Patient Script

Who I Am

I'm 46, I work in IT and I sit at a desk all day; my wife brought me in because she was worried.

What Brings Me In

My wife says I'm acting weird — I'm confused, seeing things, shaking and sweating, so she brought me to A&E.

My Story

I used to drink every day for years — usually about 10–12 units most days for the last 20 years. I had my last drink about 3 days ago. About 48 hours ago I started to feel shaky and anxious. The shaking got worse and then yesterday I started seeing things — like insects on the wall — and I couldn't sleep. This morning I was sweaty, my heart was racing and I was confused; my wife says I was talking nonsense and didn't know where I was. I feel absolutely exhausted and scared. I haven't been sick with vomiting, but I feel a bit nauseous and my hands have been trembling. I had a chesty cough a few days ago and my wife said I started some antibiotics from the GP, but I can't remember which one.

My Medical Background

Past medical history: No diagnosed chronic illnesses I know of
Medications: Occasionally take paracetamol; my wife says a GP gave me some antibiotics for a cough recently (I can’t remember which)
Allergies: None known
Social history: Smokes ~20 cigarettes/day; drinks heavily as above; lives with wife; works sedentary IT job
Family history: Father had alcohol problems

What I Think & Worry About

I think I might be having the flu or food poisoning; I just feel really unwell and frightened.
I worry I might be going mad because I keep seeing things that aren’t there.
I’m worried about being taken to hospital and missing work — but my wife says I look awful and we need help.

If You Ask Me About Other Symptoms...

On sleep: "I haven't slept properly for 2 nights — I just wake up shaking and sweating."
On visions/hallucinations: "I keep seeing little bugs and shadows moving — it's frightening."
On seizures/falls: "I don't remember passing out now, but my wife says I looked like I might have had a fit in the kitchen earlier — I felt really out of it." (wife is a bystander, can confirm)
On chest pain/breathing: "No chest pain and I'm not short of breath apart from feeling a bit breathless when anxious."
On urinary symptoms: "No burning or frequency." (red herring: recent cough and antibiotics)
On medications/substance use: "I don't normally take anything like sleeping pills, but a neighbour once gave me some tablets to try."
On headaches/focal weakness: "No focal weakness, no bad headaches — just confusion and shakiness."

Clinical Summary

Examination

General: Agitated, diaphoretic, visibly tremulous
Level of consciousness: GCS 13 (E4 V4 M5); disoriented to time and place, oriented to person only
Temperature: 38.5°C
Heart rate: 130 bpm, regular
Blood pressure: 170/110 mmHg
Respiratory rate: 24/min
Oxygen saturation: 98% on room air
Neurological: No focal limb weakness, pupils 4 mm and reactive, coarse bilateral hand tremor, visual hallucinations reported and apparent (patient points at insects on wall)
Abdominal: Mildly tender in the right upper quadrant, no guarding or peritonism; mild scleral icterus
Other: No neck stiffness, no skin rash, no peripheral oedema

Investigations

Capillary blood glucose: 6.2 mmol/L (euglycaemic)
FBC: WBC 15.0 x10^9/L (mild leukocytosis), Hb 14 g/dL, MCV 102 fL (macrocytosis)
U&E: Na 136 mmol/L, K 3.0 mmol/L (low), Cl 100 mmol/L, HCO3 22 mmol/L
Magnesium: 0.6 mmol/L (low)
LFTs: AST 120 U/L, ALT 40 U/L, GGT 350 U/L, bilirubin 35 µmol/L (mild cholestasis pattern)
Coagulation: INR 1.1
CRP: 25 mg/L (mildly raised)
Blood alcohol level: undetectable/low (last drink ~72 hours ago)
Urine drug screen: negative for opioids/amphetamines/benzodiazepines
ECG: Sinus tachycardia 130 bpm, no acute ischemic changes, QTc 420 ms
Non-contrast CT head: No acute intracranial haemorrhage or mass

Diagnosis

Primary diagnosis:

Delirium tremens (severe alcohol withdrawal) — supported by history of heavy long-term alcohol use with last drink ~72 hours ago, acute onset confusion, visual hallucinations, coarse tremor, autonomic hyperactivity (fever, tachycardia, hypertension, diaphoresis), and electrolyte disturbances; CT head and urine drug screen do not suggest alternative cause.

Differential diagnoses (with reasoning):

Sepsis-related delirium (e.g., pneumonia): possible given recent cough and mild leukocytosis/CRP rise, but no focal chest signs and presentation fits classic alcohol withdrawal timing.
Wernicke encephalopathy: confusion present, risk high in chronic alcohol use, but classical ocular signs/ataxia not prominent; nevertheless, should be considered and treated empirically with thiamine.
Intracranial event/post-ictal state: CT head normal and no persistent focal neurology, making this less likely; witness report of brief possible seizure could reflect an alcohol withdrawal seizure (fits with withdrawal spectrum).
Intoxication with other substances or sedative withdrawal: urine drug screen negative and patient denies regular benzodiazepine use; still a consideration if history unreliable.

Management

Immediate safety and monitoring: continuous cardiac and oxygen saturation monitoring; place in quiet, well-lit environment with one-to-one nursing where possible.
Airway/Breathing/Circulation: ensure airway protection if level falls; oxygen if required.
Pharmacological: prompt administration of benzodiazepines titrated to effect (e.g., IV lorazepam 2 mg increments or diazepam per local protocol) with escalation to larger doses for severe DT; consider phenobarbital or ICU transfer if refractory.
Thiamine: give IV thiamine 500 mg immediately (before glucose) and continue daily while malnutrition risk persists.
Fluids and electrolytes: IV fluids as indicated; replace magnesium and potassium (Mg and K are low) and correct other electrolytes.
Investigations and treat possible infection: obtain blood and urine cultures, chest X-ray; start empirical antibiotics only if clinical evidence of infection emerges.
Environment/adjuncts: reduce stimulation, reorientation, involve family, consider short-term physical/restraints only if necessary for safety.
Avoid routine antipsychotics as first-line for DT (may lower seizure threshold); consider only if severe agitation persists despite adequate benzodiazepines and after discussing risks.
Admit to high-dependency unit/ICU for severe autonomic instability or if high benzodiazepine requirement anticipated.
Brief interventions and referral: once stabilised, arrange alcohol liaison team input, counselling, and plan for detoxification/follow-up.

Key Learning Points

Delirium tremens is a life-threatening form of alcohol withdrawal that typically occurs 48–72 hours after last drink and presents with confusion, visual hallucinations, tremor and marked autonomic hyperactivity.
Immediate management requires aggressive benzodiazepine treatment, prompt IV thiamine, correction of electrolytes (notably magnesium and potassium), and high-dependency monitoring.
Consider and exclude other causes of acute delirium (sepsis, intracranial pathology, metabolic disturbance, sedative or other substance withdrawal) while treating empirically for likely alcohol withdrawal.