Diagnose It Answer — April 24, 2026

51-year-old male admitted 3 days ago for a femur fracture after a fall. He is now acutely agitated, confused, and diaphoretic. He is attempting to climb out of bed and has pulled out his IV. He is shouting that there are 'bugs on the wall' and grabs at things not visible to staff. His nurse notes that he had two witnessed generalized tonic-clonic seizures in the past hour.

On chart review: history of alcohol use disorder — ER records show a prior admission for alcohol withdrawal 2 years ago. Family at bedside confirms he drinks 'a fifth of vodka a day' and has done so for over 10 years. He did not disclose this on admission. His last drink was approximately 72 hours ago at the time of his injury. He also uses tobacco daily. No benzodiazepine or barbiturate use.

BP 188/112 mmHg, HR 136 bpm, RR 24 breaths/min, Temp 38.9°C (102.1°F), SpO2 96% on room air. Patient is drenched in sweat and has coarse bilateral tremors of the hands and arms. He is visibly terrified, responding to hallucinations. CIWA-Ar score: 26 (severe — score >10 indicates pharmacological treatment needed; score >20 indicates severe withdrawal).

Delirium tremens confirmed: triad of tremor, autonomic instability, and delirium. Soft restraints applied for patient safety following facility protocol and physician order. IV access re-established. Diazepam 10mg IV given for symptom-triggered protocol — repeat doses ordered q15 minutes per CIWA score. Thiamine 500mg IV given before any dextrose-containing fluids to prevent Wernicke's encephalopathy. ICU transfer initiated. Continuous cardiac monitoring and seizure precautions in place. Rapid assessment for other withdrawal differentials completed.

Blood alcohol level: undetectable (confirms abstinence from alcohol). Serum glucose: 68 mg/dL (hypoglycemia — dextrose given after thiamine). BMP: Na 130 mEq/L (hyponatremia), K 2.8 mEq/L (hypokalemia), Mg 1.2 mEq/L (hypomagnesemia — repleted; electrolyte abnormalities lower seizure threshold). Liver function: AST 248 U/L, ALT 112 U/L, total bilirubin 2.4 mg/dL (alcoholic liver disease). Ammonia: 64 µmol/L (mildly elevated). Urine drug screen negative for other substances. CT head: no acute hemorrhage.