Posted by King from IP 71.196.92.103 on September 30, 2006 at 12:20:47:
A 57-year-old man with schizoaffective disorder, whose symptoms were in remission until 2 weeks ago, is brought to the emergency department by his girlfriend. He will not talk with you but the girlfriend tells you that he has a history of "overdoses", and she is afraid he has taken a lot of "his pills". He has been complaining of voices telling him he "should be dead". He has not left the house in a month and has spent several hours a day looking out the window for the "king and savior" to "come take him". His medications include haloperidol, valproic acid, and a small dose of amitriptyline for chronic pain related to nerve damage in his leg, which occurred in a motor vehicle accident 10 years ago. He has no other medical problems. A chart review reveals that he has no allergies and was diagnosed with schizoaffective disorder 30 years ago. His temperature is 37.0 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 26/min. He is a depressed appearing man with very poor eye contact. He smells of alcohol. He does not acknowledge you, but will answer some questions for his girlfriend. He does admit to feeling that "life is not worth living" and feeling "more religious than usual". He seems slightly drowsy and knows the date. His physical examination is normal. The most appropriate next step in management is to order
A. acetaminophen and salicylate levels
B. blood alcohol level
C. electrocardiography
D. urine toxicology for street drugs
E. valproic acid level