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You are an F2 on the Acute Medical Ward and have been asked to see Mrs Eftees, a 54 year old lady who is noted to be confused, found by her family at home to be disorientated. Her GP note refers to a recent presentation to the surgery with ‘confusion’. It is noted also that her husband unfortunately passed away a few months ago.

Elle has a history of rheumatoid arthritis and Type 2 diabetes for which she takes multiple painkillers and metformin.

Please take a history and carry out a mental state exam for this lady. You will then be asked to discuss the case with the examiner.

You are Elle, a usually friendly and outgoing lady who retired 3 years ago from being a headteacher. You and Bill married at 21 and never had children. You are not quite sure what is going on at the moment, are easily distractible and keen to change the subject at all times as you feel quite restless.

You are distressed at being somewhere unfamiliar and mention nuns, and wonder if you are in trouble. You really want to go home, and so you feel that you must ask the doctor repeatedly if you can go home, as Bill will be waiting in the car.

Medically, you feel absolutely fine, but must head home. You feel that your mood is fine - why wouldn’t it be? You’ve never had any thoughts of harming yourself or suicide: you could never do something like that to Bill! You don’t know what you would do without each other.

You do have a glass of sherry now and again: isn’t a lady entitled to a drink from time to time? You’re not one of those horrible binge drinking kids you used to teach - that wouldn’t be proper! You don’t smoke as you feel it is a horrible habit.

You don’t recall hearing or seeing anything unusual: what an unusual question!

In all, you don’t really have any specific medical problems, but you really must go as Bill is waiting for you!

The candidate should present back a MSE covering appearance, behaviour, rapport, speech, mood and thought. An excellent candidate will approach the history with care and delicately explore Elle’s understanding of her home situation, maintaining her dignity and showing compassion.

A differential diagnosis may include grief reaction (either abnormal or within range of normal), depression, delirium or dementia. The merits of each should be discussed. It would be pertinent to ensure that the patient’s blood sugar was checked as a hypoglycaemic event may contribute to symptoms.

Topics for discussion may include:

  • What is an abnormal grief reaction?
  • How is abnormal grief reaction treated?
  • What is the difference between dementia and delirium?
  • Can you name some causes of delirium?
  • Can you name any drugs which may contribute to delirium?