You are a second year emergency medicine resident working the night shift in the ER. The police bring in a 36-year-old white woman on a legal hold. Per the hold, the police found the woman in the middle of the freeway jumping up and down. Due their inability to understand her rapid nonsensical speech, she was brought in the ER as gravely disabled and a danger to herself. Police search of the women’s belongings is significant for a return plane ticket receipt from Las Vegas and an empty bottle of lithium.

You suspect manic exacerbation of Bipolar 1 disorder and call for a stat psych consult. In the interim, prior to psychiatric interview, you order a urine drug screen, a lithium level, a thyroid panel, a chemistry panel and a CBC with differential. While the patient is being interviewed by the psychiatry resident, the labs come back within normal limits with the lithium level being 0.0 mEq/L. Soon after, the psych resident informs you that the patient will be admitted to the hospital and you congratulate yourself again on clearing out the ER.

authored by Nathan Lavid, M.D.
Department of Psychiatry
University of California, Irvine
(used with permission)