CC: 53 y/o female with psychosis

HPI: 53 y/o Native American female brought to the ED from a NH this morning with

altered mental status and psychosis. She had been discharged from the hospital 4 days

prior after a right total hip arthroplasty. She was discharged to a rehab facility and was

doing well until the evening prior to admission. At 6am on day of admission, pt refused a

lab draw and stated “they can take it at the hospital, I’m waiting on the ambulance”.

Throughout the day, she continued to make non-sensical comments but remained

cooperative and responsive. She was noted to be talking to herself and to people that were

not present. Because of these symptoms, staff at rehab transferred to Regions for

evaluation. Continued to hallucinate in ED demonstrated as talking to imaginary people.

Became increasingly agitated. Given IV ativan with decreased both agitation and lucidity.

PMH:

Osteoarthritis

DJD

Multiple fractures 2/2 pedestrian vs vehicle MVA in 1980

HCV

Depression

ADHD

PSH:

s/p anterior cervical discectomy and fusion at C5-6, C6-7 May 2006

s/p right THA and hardware removal on 12/6/06 after failure of THA from 1980

s/p c-section 2/2 sepsis 1987

s/p ex lap 2/2 perforated colon 1975

ROS: unable to obtain secondary to mental status

Meds:

Cymbalta 30mg qday

Wellbutrin 300mg qday

Tramadol 40mg qid

Ambienc 10mg qhs

Adderall 20mg qday

Percocet 102 tabs q4h

Lorazepam 1mg qday

Hydroxyzine 25mg, 1-2 tabs q4h prn

Docusate

Hexavitamin

Calcium/vit D

Warfarin 1mg

Shx:

Living at rehab after recent hip surgery. Smokes 1 cigar/day. Divorced. No employment

secondary to MVA injuries from past.

Fhx: Mother had CAD and died of ruptured brain aneurysm/stroke. Father died of MI.

Exam:

VS: T 97.2F, BP 116/84, HR 120, RR 19, O2S 95% RA

Gen: Agitated and lying in bed. Opens eyes to voice intermittently. Tremulous and

diaphoretic.

HEENT: Normocephalic and atraumatic. PERRL. Pt will not cooperate with opening

mouth for OP exam.

Neck: No masses. Trachea midline. Carotids 2+

Lungs: CTA bil, no wheezing or rales

CV: Tachycardic, regular. S1 and S2 normal, no m/r/g

Abd: soft/nt/nd. Bowel sounds normal to hyperactive.

Ext: 1-2+ pitting edema in RLE. LLE without edema. Right hip surgical site is c/d/I with

mild serosanginous drainage. DP and PT pulses 2/2.

Neuro: Not able to follow commands. Opens eyes to pain, voice and touch. Visible

tremors in bil lower extremities. Spontaneous clonus in RLE, inducible clonus with

multiple beats in bil LE, but R>L. Patellar reflexes 3+ bilateral. Biceps reflexes 2-3+ bil.

Bil LE exhibit rigidity bilaterally. Unable to illicit babinski sign due to rigiditiy.

Labs:

• CBC: WBC 10.9 (normal diff), HGb 9.2, Plt 256

• BMP: Na+ 138, K+ 4.0, Chl 107, CO2 25, BUN 12, Crt 0.8, Ca2+ 8.0

• Utox: preliminary presumed pos for amphetamines and THC

• CK 662

EKG: sinus tachycardia

Head Ct: exam was limited by motion. Ventricles and sulci normal. No obvious

intracranial abnormality.

Course:

Agitation/psychosis picture consistent with serotonin syndrome (agitation, rigitidy,

neuro findings).

- started CIWA ativan parameters.

- Attemped cyprohepatdine 12mg PO x1 dose.

- Admitted to MICU

- Started NS at 150ml/hr

- Supportive cares

Libby Zion/Work Hours:

18 y/o female who presented to New York Hospital Cornell Medical Center with fever,

agitation, and “strange jerking motions” of her extremities. Ongoing treatment for

depression. Was admitted and evaluated by an intern and a resident. After discussing the

case with the pts PCP, decided she had a viral illness with “hysterical features” and she

was given mepiridine for pain and sedation. Pts status worsened overnight and crosscover

was notified. However, intern was covering 40-50 other patients some of whom were

very ill. Restraints and haldol were administered. Pt developed fever to 107F, had cardiac

arrest and died.

Family sued for inadequate staffing at teaching hospital. Claimed that long hours and too

many patients were to blame for poor care their daughter received. Father was journalist

at NY Times. Blaimed administration of mepiridine interaction with anti-depressant

caused serotonin syndrome and pt died.

After many trials and cases led to the Bell commission with recommendations for no

more than 24hours of patient care, limit of 80 hours in a work week, and presence of

attending physician in house at all time. New York state first to accept these restrictions

ACGME accepted 80 hour work hour restrictions with no more than 24 hours of active

patient care in 2003. Has caused great amount of discussion and changed through medical

training.

DDx:

Neuroleptic malignant syndrome- longer course, bradyreflexis, muscular rigidity, caused

by dopamine antagonist

Anticholinergic toxicity- muscular tone and reflexes are normal in AC toxicity

Malignant hyperthermia

Intoxication with sympathomimetic agents

Neuro:

Meningitis

Encephalitis

ID:

bacteremia from hip

endocarditis