A 54-year-old white woman with a history of depression is brought to the Emergency
Department by police on an involuntary mental health hold secondary to out-of-control
behavior. Police were contacted by her daughter, who reports the patient has not been
sleeping and has become increasingly agitated. History is difficult to obtain, as
on examination, her speech is pressured and illogical. Her daughter describes her
behavior as a dramatic change over the last few days. On review of systems, she has
a worsening cough and shortness of breath, fever, and 4 kg (∼9 lb) weight loss over
the last few weeks. She appears jittery on observation, is pacing within the examination
room, has a noticeable tremor, and is profusely diaphoretic. She also has a nonproductive
cough. On physical examination, her vital signs include a temperature of 39.5°C (103°F),
a heart rate of 135 beats/min, a blood pressure of 160/75 mm Hg, and a respiratory
rate of 20 breaths/min, with an oxygen saturation of 96%. Her skin is noted for erythema
and her palms are damp. Her lower extremities are notable for pitting edema. An electrocardiogram
shows sinus tachycardia. Urine toxicology is negative. Metabolic panel and blood count
are remarkable for leukocytosis (14.2 cells/L), hypercalcemia (11.7 mg/dL), and elevated
transaminases (AST 287 U/L, ALT 245 U/L). She is oriented only to person. She becomes
irritable with continued assessment and reports she needs to leave the hospital to
give a presentation on world peace to the United Nations. When told she cannot leave,
she becomes agitated and assaults a staff member, requiring physical restraints.
Keywords
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Article info
Publication history
Published online: May 31, 2016
Accepted:
January 22,
2016
Received in revised form:
December 19,
2015
Received:
August 31,
2015
Identification
Copyright
© 2016 Elsevier Inc. All rights reserved.
