Editor's Note:The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

An 88-year-old woman who has had confusion and a decline in mental status over the past 2 weeks is brought to the emergency department by her daughter. The patient's daughter reports that her mother has also had occasional hallucinations for the past week, with associated intermittent moaning. She is unable to provide a history for herself, and all history is gathered from her daughter.

Her past medical history is significant for hypertension and skin and breast cancer; she had a partial mastectomy 10 years ago. The only medication she takes daily is metoprolol for hypertension.

Forty-five days ago, the patient underwent an open reduction and internal fixation of a left femur intertrochanteric fracture. The surgery was uncomplicated, and she was discharged from the hospital to a rehabilitation facility 35 days ago. Before the fracture, the patient was independent; she lived alone and went to a bar every night with her friends. According to her daughter, she does not use tobacco or illicit drugs.

Her daughter noticed that her symptoms of confusion started 2 weeks ago and have progressively worsened. She removed the patient from the rehabilitation facility 5 days ago owing to "improper care." Her daughter also reports that her mother's baseline status is alert and oriented to person, place, time, and event. Her decline in mental status has occurred over the past 2 weeks and has worsened during the past 3 days. The daughter reports that her mother has not had chest pain, shortness of breath, nausea, vomiting, or diarrhea; however, she has had multiple episodes of abdominal pain and deep bone pain over the past 2 weeks.

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Cite this: Danny Gersowsky.Internal Medicine Case Challenge: Hallucinations, Moaning, and Confusion in an 88-Year-Old-Medscape-May10,2023.

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