Altered Mental Status in a Young Man Picked Up On the Street

Andréa B. Lese, MD, MA; Rick G. Kulkarni, MD

Disclosures

October 05, 2018

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 recognize accurately. 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.

Background

A 33-year-old man is brought by ambulance to the emergency department (ED) with altered mental status and agitation. He had called 911 from a pay phone, stating that people were trying to shoot him. Upon arrival of the police to the scene, the patient was reported to be visibly paranoid, so Emergency Medical Services (EMS) was called.

En route to the hospital, the patient became more confused and combative. EMS requested and received authorization to give intramuscular midazolam. A total of 4 mg was given, but 8 people were still needed to control the patient and get him into the ED and onto a gurney.

On arrival, the patient is unable to provide much meaningful history of his present illness, but he is coherent enough to deny any previous medical problems, allergies, or prescription medication use (other than methadone). He does admit to using cocaine.

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