DOI: 10.36347/sasjm.2016.v02i02.003

Pages: Page: 35-39

We report a case of a 59 year-old female with a history of bipolar I disorder with psychotic symptoms who presented to the Emergency Department (ED) with cough and request for medication refill. During the course of her stay, the patient was noted to have an altered mental status (AMS). Specifically, the patient was not only confused and disoriented but frankly delusional with a disorganized thought process. Her review of systems was notable for a nonproductive cough and her physical exam was unrevealing. Her initial lab results were unremarkable except for a mild leukocytosis. She was initially diagnosed with pneumonia and started on antibiotics. The Emergency Department medically cleared the patient for psychiatric evaluation. A psychiatric consultation was placed for suspected mania secondary to psychiatric illness given her medication non-compliance. During the psychiatric evaluation, she became more confused and combative - her behavior was concerning more for delirium than mania. Consequently, the psychiatry team requested additional ingestion labs including aspirin and acetaminophens levels and requested the ED entertain possible medical explanations for the patient‟s condition. Seven hours after initial evaluation and during “discovery rounds” and transfer of patient care to the overnight team, her salicylate level was shown to be elevated to 75.7 mg/d and her venous blood gases showed significant mixed respiratory alkalosis and metabolic acidosis, causing further concern for salicylate toxicity. The overnight team obtained collateral information that revealed that the patient chronically ingested “BC Powder”,