Case #62 "Scared to Death…"
by Charlene Babcock Irvin, MD

The last case of a busy sign-out is a 20ish y/o male brought in by EMS after he was found collapsed outside a plant. According to the guards at the plant, the patient was trying to cut through the large, fenced-in parking lot when the guard dogs began to chase him. He was able to barely outrun the dogs, and collapsed on the other side of the fence. Guards noted he ran ‘a good while’ before jumping the fence to safety. EMS noted he was incoherent, and intermittently combative. Police assisted at the scene to restrain the patient for EMS. He is unable or unwilling to give his name or age.

Initial BP was 160/110, with heart rate 140. Oxygen saturation = 100% on two liters nasal canula. Acucheck was 110. He was initially evaluated in the critical care area in the ER, and the physician leaving, noted he was uncooperative and refusing to answer questions. When she tried to look in his eyes, he became wild, thrashing inappropriately, and pushing everyone away. As he was very agitated and acting psychotic when trying to examine him, security helped place temporary physical restraints while chemical restraints were started. He was given Haldol (5 mg) and Ativan (2 mg) IM. Labs and IV were ordered, oxygen started, and a RUDS (rapid urine drug screen) and CT of head was ordered.

The leaving doc felt he likely was intoxicated (drugs?) or psychotic, or both. He had no ID, so there were no records or clues to his past history.

As I walked by, I saw a young male, lying still with his eyes shut, diaphoretic. Nurses were at the bedside initiating an IV. Monitor was cycling the blood pressure, and the technician was placing him on the monitor. The Haldol and Ativan seemed to be working as he was not actively resisting attempts to put the tourniquet on.

There were six new patients to see, so I began with the two having chest pain (a resident saw one, and I saw the other), and then moved on to the 3 y/o child who just had a seizure (and had a fever). The shoulder injury, diarrhea, and ankle pain would have to wait.

While still in the pediatric area, an EKG was given to me to review. I noted a left bundle branch block, with tachycardia (heart rate = 120). I immediately asked if there were any old EKG’s and if the patient was having chest pain (being concerned the patient was having the equivalent of a STEMI…a new left bundle branch block with chest pain is the same as a STEMI and needs rapid mobilization to the heart catheterization lab). However, the age on the EKG read 30 yrs old. The tech told me it was the psychotic patient that is now calm enough that they could get the EKG. He told me there was no old EKG as they didn’t know his name.

As I walked back to evaluate the psychotic patient, he was lying quietly on the gurney, the monitor read blood pressure of 155/105, and the HR was still 120. He was slightly diaphoretic, with a respiratory rate of 30.

When I gave him a sternal rub, he would answer some simple questions. He kept saying ‘ran too hard’ and ‘thought I would die’. He said he had pain ‘all over’, including his chest. He also admitted to doing “a lot’” of cocaine earlier. He did admit to shortness of breath, but no nausea or vomiting.

It was not possible to get review of systems, but he denied any other medical problems. He did give me his first name, but wouldn’t give his last name. The nurse noted that this was a significant improvement as he was now making some sense and would answer some questions.

Physical Exam:

HEENT: PERRL, Neck supple, patient would not open mouth for exam, but the limited speech he offered was clear and he was handling his secretions.
Heart: Tachycardic. No murmurs
Lungs: Clear, still tachypnic with RR about 24-28
Abd: soft, scaphoid. No tenderness
Ext: Skin warm to touch, diaphoretic. Pulses strong. No rashes.

Neurological Exam:

Patient would move all 4 extremities, did not cooperate with cerebellar or cranial nerve testing (but no obvious abnormality noted), reflex's present and normal. Would not answer mental status questions, but mental status appeared to be improved from arrival as he would answer some simple questions. Sensation appeared grossly normal.

The Cardiology fellow was paged (cocaine with chest pain, ? new LBBB = STEMI equivalent), and the patient was moved to the critical care area, and a second IV was started. Oxygen and telemetry were maintained. As I’m answering the call to the cardiology fellow, the nurse informs me the potassium was elevated at 7.2, but was also hemolyzed, so she had just repeated it.

1. What do you do now?

2. The rest of the renal panel was remarkable for decreased bicarbonate of 10, and an elevated BUN/Cr of 35/3.9. Urine drug screen was positive only for cocaine. He states he feels a “little bit” better after your treatment (for question #1). A bedside Echo shows a hyperdynamic heart with normal wall motion. Portable CXR normal. He now tells us his last name, and seems more responsive. (eyes open to sternal rub, confused but will answer some questions appropriately, localized pain: GCS = 2 +4 +5=11.) According to his old records, he has a history of schizophrenia and drug abuse.

Repeat potassium is now back at 7.8. Foley reveals urine output of 500 cc with dark concentrated urine. He has received two liters of fluid, and his pressure has dropped to 110 systolic. Initial CPK is 2200, with normal troponin. MB index is not elevated. CBC is remarkable for a HBG of 15, and a WBC of 15K. Who you gonna call?

3. The phosphorus now comes back at 23 mg/dl (severely elevated upper limit of normal is 3.0). What do you think now?
 

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