A 65-Year-Old Man Brought to the ED by Military Police

Jeffrey S. Forrest, MD; Alexander B. Shortridge

Disclosures

August 06, 2019

Physical Examination and Workup

Upon physical examination, the patient is 5'9" (1.79 m), weighs 243 lb (110.5 kg), and has a body mass index (BMI) of 35.9 kg/m2. His pulse is 94 beats/min, his respirations are 18 breaths/min, his blood oxygen level is 97%, his temperature is 97.8° F (36.6° C), and his blood pressure is 138/104 mm Hg.

Initially, the patient continually repeats his name, rank, and serial number. When he eventually begins answering questions, the patient appears alert and oriented to name, location, date, and time. He is appropriately groomed and in no acute distress. In recall, he does well in immediate, recent, and long-term memory. His behavior is calm and attentive, with no excessive body movements and good eye contact. His speech has normal rate, rhythm, volume, and prosody.

Substantive delusional thought content is appreciated. He believes that he is a prisoner of war. His emotional tone is consistent with delusional thought constructs. He uses military jargon. He denies suicidal ideation at the time of his interview. He denies being homicidal but says that if he or his wife are in danger, he will "defend them."

He states that his mood is good, and his affect is congruent with his stated mood. Neither his wife nor son report having noticed any significant signs or symptoms of depression at any point in his history. The patient neither confirms nor denies any auditory or visual hallucinations, derealization, or depersonalization. Although the patient appears able to attend to the interview, he does not cooperate with the serial sevens examination. His insight is poor, as he demonstrates significant reality-testing impairments. He is unable to assess situations correctly or appropriately, and clearly has evidence of dangerous decision-making.

Laboratory findings are as follows:

  • Total bilirubin level: 1.8 μmol/L

  • Blood urea nitrogen level: 21 mg/dL

  • Creatinine level: 1.5 mg/dL

  • Sodium level: 140 mmol/L

  • Potassium level: 3.9 mmol/L

  • Red blood cell count: 5.2 x 1012/L

  • Hemoglobin level: 15.9 g/dL

  • Hematocrit level: 46%

  • White blood cell count: 12.9 x 109/L

An ECG reveals marked left axis deviation and incomplete right bundle branch block (QT/QTc 406/41). A CT scan of the head is unrevealing. His urine drug screen results are negative.

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