A shaky post-operative course in an elderly patient
Case by Barbara H. Fadem-Chenal, Ph.D. & Petros Levounis, M.D.
The case below is followed by a choice of diagnoses. Select the one lettered selection that best describes the patient’s condition.
A thin, frail, 76-year-old woman is brought to the hospital after a fall outside of a neighborhood restaurant. Radiologic studies indicate a right femoral neck fracture, and the patient is admitted to the orthopedic surgery service for an emergency hip replacement. The patient’s admission labs are notable for mild liver function test (LFT) elevations and mildly low albumin. Otherwise, complete blood count (CBC) and comprehensive metabolic panel (CMP) are normal, patient’s blood alcohol level (BAL) is zero, and her urine toxicology examination is negative for all substances.
After the surgery, the patient is given oxycodone as needed for pain. While at first the patient seems to be doing well, two days later, she begins to show an intense hand tremor and tachycardia as well as increased temperature, blood pressure, and respiration. She tells the doctor that she has felt “shaky” ever since the surgery and that the shakiness is getting worse. The patient states that although she feels very frightened, she is comforted by the fact that the nurse who is treating her is a dear old friend (she has never met the nurse before). She also reports that she has started to see ants crawling on the walls and can feel them crawling on her arms. The wound seems to be healing well, the results of a CBC are unremarkable, and the nurse reports that, over the last day, the patient has asked for pain medication only every 6 to 8 hours rather than every 3 to 4 hours. The doctor notes that during a physical examination, the patient seems distracted and her speech is drifting from one subject to another.
What is the clinical diagnosis of this patient’s condition and its underlying pathophysiology? How should it be managed?
A. Alcohol withdrawal delirium
B. Reaction to the anesthetic used for surgery
C. Alzheimer’s disease
D. Opioid withdrawal
E. Occult staphylococcus wound infection
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