Alcohol withdrawal and delirium tremens — structured clinical viva

Diagnosis. Delirium tremens — ~55 hours after last drink, fluctuating consciousness, severe autonomic hyperactivity, formed hallucinations. This is a medical emergency, not primary schizophrenia-spectrum psychosis.[1][2]

Differential. Medical delirium (infection, metabolic, head injury), Wernicke encephalopathy (may coexist), alcohol hallucinosis without delirium (sensorium clearer), benzo withdrawal if co-dependent, hepatic encephalopathy if cirrhotic.[2][7]

CIWA issue. A score obtained while obtunded is not reliable. CIWA-Ar requires an assessable patient; do not withhold treatment based on a falsely low score.[3][6]

Unsafe plan. Tiny single-dose oral diazepam under-treats DT; olanzapine monotherapy does not fix withdrawal hyperexcitability. Need aggressive benzodiazepine titration (often parenteral; e.g. repeated diazepam or lorazepam doses per protocol until calm and autonomics improve), continuous monitoring, ICU if refractory/respiratory risk, electrolytes, and parenteral thiamine (high-dose EFNS-style, e.g. 500 mg IV TDS initially when Wernicke risk).[1][4][5][6]