The patient is a 38-year-old African American male with a past medical history of schizoaffective and bipolar disorder who presented to the ED with altered mental status and chest pain. The patient had been issued a day / evening pass to leave the psychiatric facility where he currently resides and spent the evening at home with family. Upon returning to the facility, the staff noted the patient “appeared out of it” and somnolent.  After the patient reported chest pain, the psychiatric facility called EMS. Per EMS and facility staff, the patient was difficult to arouse and maintained an altered mental status.

In the emergency department, the patient repeatedly fell asleep in the exam room but arose to verbal and physical stimuli. On exam the patient endorsed pleuritic chest pain and “sinus congestion.” The patient also had a productive cough with rust tinged sputum. The patient reported his family members had “shared their sinus congestion medicine with him.” The patient remained somnolent throughout the exam.
Other than a history of psychiatric disorders, the patient is normally otherwise healthy, with no previous surgeries. He denied alcohol, smoking, or any drug abuse. The patient’s daily medications included: benztropine (Cogentin 2 mg oral tablet) and zolpidem (Ambien 10 mg oral tablet).
Due to the patient’s altered mental status, a more thorough history was difficult to obtain.
Physical Exam
Vitals: P= 104/min; RR= 16/min T= 36.4 C (97.5 F); BP = 115/70 mmHg; Pulse Ox: 98%
Skin:  Warm, dry, no pallor, no needle tracks
Eye:  Pupils pinpoint, equal, round, sluggish but reactive to light. Extra ocular movements intact, no nystagmus
ENT:  Patent airway. No pharyngeal erythema or exudate.  
Neck:  Supple, trachea midline, no stridor
Lungs: Right side = clear to auscultation. Left side = left lower lobe significant for diminished breath sounds with noted crackles and dullness to percussion.
Heart:  Sinus tachycardia with sinus rhythm, normal S1 & S2, no murmurs.
Abdominal:  Normal bowel sounds.  Soft.  Nontender.  Non-distended.  
Back:  Nontender. Normal range of motion.  Normal alignment.  
Extremity:  Normal range of motion.  Normal tone.  No swelling.  No tenderness.  
Neurological: Alert when aroused to verbal and physical stimuli. Disoriented, changing stories multiple times, sleepy, nodding off; no aphasia, no dysarthria.

Laboratory Data
CBC: WBC = 31K RBC = 3.6 Hgb/Hct = 35/12 PLT = 219K
BUN/Cr: 32/1.7 Glucose = 130
CXR: Left lung opacity, within the lingula, suspicious for pneumonia.
U/A:  0 WBCs  0 RBCs
Urine toxicology screen: Negative for opioids, benzodiazepines, cocaine, PCP, amphetamines, cannabinoids
APAP/ASA levels: nondetectable;
ETOH= zero
ECG: sinus tachycardia rate 100 beats per minute, no ischemia, no ectopy


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