Alcohol use disorder — structured clinical viva

Diagnosis. Delirium tremens — ~50 hours after last drink, fluctuating consciousness, severe autonomic hyperactivity, formed hallucinations. This is a medical emergency, not a primary behavioural disturbance.[1]

Differential. Other delirium (infection, metabolic, head injury from trauma), Wernicke encephalopathy (may coexist), alcohol hallucinosis without full delirium, benzo withdrawal if co-dependent, hepatic encephalopathy if cirrhotic.[1][3][6]

Immediate management. Continuous monitoring; CIWA-Ar if usable but do not withhold treatment if unassessable; high-dose benzodiazepines titrated to control agitation/autonomics (agent choice: diazepam or lorazepam if liver disease — name local protocol); parenteral thiamine high-dose if Wernicke risk; electrolytes (Mg/K/phosphate); medical/ICU escalation if refractory. Antipsychotics are not first-line for DT physiology.[1][2][6]

Naltrexone tonight. No while on oxycodone — precipitated opioid withdrawal and blocked analgesia. After opioid-free interval and consent, oral naltrexone 50 mg daily (or XR-NTX later) is reasonable; alternatives acamprosate 666 mg TDS or supervised disulfiram. Pair with psychosocial care; cite COMBINE nuances if asked.[4][5]