EM Forum Case #119 "Just Acting Out"

by Charlene Babcock Irvin, MD, FACEP  

As I’m walking down the hall, I hear a patient yelling ‘I’m in severe pain.’ The patient can also be heard refusing to get undressed and continues to repeat “I’m in severe pain’. Because of the obvious disruption and complaint, I immediately walk into the room. The nurse looks exacerbated and frustrated holding a gown open for the patient to get dressed into. The patient is lying in the fetal position moaning and fully dressed. Her boyfriend is with her trying to convince her to get into the hospital gown.

I pick up the chart with the chief complaint of ‘hit her head’.

I introduce myself, and ask the patient how I can help her. She refuses to answer and just yells out, “I’m in F@#$%&@ pain!!” I need pain medication! I don’t want to keep repeating myself!”

I look to the boyfriend for more information. He notes that she lives with him, and 2 days ago she left early in the morning (he is not sure why she left), and must have slipped on the ice because he went to check on where she went about 5 min later, and found her on the ground on the sidewalk outside their house. He thinks she was knocked out, but when he got there, she was waking up. He helped her inside, and she wanted to go to bed. She has been sleeping a lot, and only gets up to drink some water. Yesterday she complained of a headache, and today she is still complaining of a headache, so he brought her in. She is able to go to the bathroom, and can walk to the kitchen to get water. There is no vomiting. Today she seemed to have a problem walking, so he brought her in to the ED.

When I ask him if it’s unusual for her to be crying out and screaming in a high pitch, he responds, “You mean like the whining she is doing now. Yea, she can get like this if she doesn’t get her way.”

Patient hears the boyfriends comment, and abruptly turns around and yells, “I hit my head and it F%*&$% hurts. I asked to go to the emergency room yesterday, but he refused to take me.”

During the following few minutes, most of the history is from the boyfriend. Patient at times seems coherent, but at other times seems to ramble about other things that don’t make sense.

PMH: Boyfriend notes she has had 3 seizures when she ran out of Xanax. She lives with him and he doesn’t know of any other medical problems. Her father did hit her in the head last month, but she didn’t report him and did complain of a headache at that time. She never went to the doctor for that.

Meds: Boyfriend states she takes Xanax for her nerves, but ran out last week. He then notes that she may have had a seizure when she fell as she has a history of seizures. She is not on any medication for seizures. He denies any previous psychiatric admissions.

SH: smoker and social drinker. He denies that she injects drugs.
FH: Unknown, she has little contact with her family, who are abusive.

PE: Difficult as patient is not cooperative. 130/80, P=110, RR=20, T=98.6, Sat 98% RA

HEENT: Pupils round, light reaction is very difficult as patient won’t open her eyes for light testing. She does have photophobia and screams when you try and shine a light into her eyes. From my quick exam, I believed they were reactive. I’m unable to check fundi. She does have a scalp contusion on her occiput with some old blood. I am not able to examine it as she begins to scream and push me away. Clearly it is tender. Neck appears to be non-tender. The airway is open, no tenderness to face. TM without blood. Mucus membranes dry.

Heart: Tachy at 110, no other abnormalities

Lungs: Clear

Abd: soft scaphoid non-tender

Ext: normal

Neurologic: Exam difficult as patient is not cooperative. She will sometimes follow some commands. She spontaneously moves all 4 extremities. No gross cranial nerve abnormalities are noted but complete exam not possible. Sensation is grossly intact as she responds to stimuli in all 4 extremities. Mental status is clearly abnormal, but when pushed, she does note the correct month and year. She doesn’t know what hospital she is at. She will randomly ask strange questions such as: “When did the fire start?” Patella reflexes are normal, and Babinski is down going. Unable to test gait or cerebellar exam. Her GCS is 13 as she is confused about where she is, and is lying with her eyes shut.


Questions:

1. What are 2 critical actions that need to be done now?

2. Should you give her pain medication?

3. Should you give her a benzodiazepine?

4. What do you think her CT revealed?

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