Differential Diagnosis

The patient's presentation suggests a complex interplay of psychiatric, neurological, and substance-related factors. Given her history of alcoholism, recent withdrawal, and current symptoms, the following differential diagnoses are considered:

• Single Most Likely Diagnosis

  • Delirium Tremens (DTs): This is a severe form of alcohol withdrawal characterized by confusion, agitation, hallucinations, and delusions, which aligns with the patient's symptoms. The history of recent alcohol withdrawal and the timing of her symptoms (occurring after a recent hospital discharge for alcohol withdrawal) support this diagnosis.

• Other Likely Diagnoses

  • Alcohol Withdrawal: Although the patient was recently treated for alcohol withdrawal, the possibility of ongoing or recurrent withdrawal symptoms, especially given her early discharge against medical advice, cannot be ruled out.
  • Wernicke's Encephalopathy: This condition, caused by thiamine deficiency, is common in chronic alcoholics and can present with confusion, ataxia, and ophthalmoplegia. Although the patient received thiamine during her recent hospitalization, the duration and adequacy of treatment might not have been sufficient to prevent or fully treat Wernicke's encephalopathy.
  • Psychotic Disorder: The patient's delusions of persecution could suggest a primary psychotic disorder, but given her history of alcoholism and recent withdrawal, this seems less likely as the primary diagnosis.

• Do Not Miss Diagnoses

  • Infection or Sepsis: Fever, which could be masked by the patient's agitation and diaphoresis, is a critical sign that should not be overlooked. Infections can precipitate or exacerbate confusion and agitation in vulnerable individuals.
  • Trauma or Head Injury: Given the patient's confused and agitated state, and the fact that she was found wandering aimlessly, the possibility of an underlying head injury or other trauma should be considered.
  • Hypoglycemia or Electrolyte Imbalance: These conditions can cause confusion, agitation, and a range of other symptoms, especially in someone with a history of alcoholism and potential poor dietary intake.

• Rare Diagnoses

  • Korsakoff's Syndrome: A chronic condition related to Wernicke's encephalopathy, characterized by memory loss and confabulation. While possible, this diagnosis might not fully explain the patient's acute presentation.
  • Alcoholic Hallucinosis: This condition involves auditory hallucinations in a clear sensorium, usually occurring within 12 to 24 hours after the last drink. It's less likely given the patient's confused state and delusions of persecution.