A 30-Year-Old Man With Paranoia and Vomiting After a Party

Warren C. Harvey, MD


June 14, 2023

Physical Examination and Workup

The patient appears anxious. He is vomiting and tearful. His heart rate is tachycardic, at over 130 beats/min. His blood pressure is 140/89 mm Hg, respiration rate is 20 breaths/min, and temperature is 98.6°F (37°C). His pupils are dilated and reactive; mild conjunctival injection is noted. His skin is diaphoretic and warm to the touch.

Results of the cardiac examination are normal, with the exception of tachycardia. His lungs are clear to auscultation bilaterally. Examination of the abdomen reveals mild diffuse tenderness without focal peritonitis or localized discomfort. The neurologic examination demonstrates normal cranial nerve testing results, normal strength and sensation in the upper and lower extremities, normal reflexes, and normal gait testing results. However, the patient is experiencing lightheadedness when he stands up. The patient is alert and oriented to self and place but remains agitated and paranoid. No clonus or muscle rigidity is noted. Deep tendon reflexes are normal. The patient is able to provide a urine sample.

The initial diagnostic workup in the ED includes ECG, complete blood cell count, basic metabolic panel, urine drug screen, and ethanol level. Owing to the patient's undifferentiated altered mental status and vomiting, noncontrast head CT is ordered as well.

The ECG shows sinus tachycardia with a normal axis, normal intervals, no ST elevations, no ST depressions or T wave inversions, no Brugada sign, no delta wave, and no prolonged QT. An example of an ECG similar to the patient's is shown below (Figure 1).

Figure 1.

Other findings are as follows:

  • White blood cell count: 11 × 109 cells/L (reference range, 4.5-11.0 × 109 cells/L)

  • Hemoglobin level: 14 g/dL (reference range, 13.5-17.5 g/dL)

  • Platelet count: 350 × 109 cells/L (reference range, 150-400 × 109 cells/L)

  • Sodium level: 129 mEq/L (reference range, 135-145 mEq/L)

  • Potassium level: 3.2 mEq/L (reference range, 3.7-5.2 mEq/L)

  • Chloride level: 90 mEq/L (reference range, 98-106 mEq/L)

  • Bicarbonate level: 26 mEq/L (reference range, 23-30 mEq/L)

  • Blood urea nitrogen level: 10 mg/dL (reference range, 7-20 mg/dL)

  • Creatinine level: 1 mg/dL (reference range, 0.7-1.2 mg/dL)

  • Glucose level: 150 mg/dL (reference range, 74-106 mg/dL)

  • Creatine kinase level: 200 IU/L (reference range, 55-170 IU/L)

  • Troponin level: < 0.01 ng/mL (reference range, 0-0.4 ng/mL)

The results of the urine drug screen and the ethanol level are pending. Noncontrast head CT reveals no acute intracranial abnormalities. An example of a CT scan similar to the patient's is shown below (Figure 2).

Figure 2.


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