1) 53 year old Native American female with history of osteoarthritis, depression, ADHD presented with altered mental status and psychosis 4 days after hip surgery. 2) On examination, she was agitated and diaphoretic with tremors in lower extremities and hyperreflexia. Labs showed elevated CK consistent with serotonin syndrome. 3) She was diagnosed with likely serotonin syndrome from an interaction between her antidepressants and possible amphetamine or THC use, and was admitted to the ICU.

1. CC: 53 y/o female with psychosis
HPI: 53 y/o Native American female brought to the ED from a NH this morning with
altered mental status and psychosis. She had been discharged from the hospital 4 days
prior after a right total hip arthroplasty. She was discharged to a rehab facility and was
doing well until the evening prior to admission. At 6am on day of admission, pt refused a
lab draw and stated “they can take it at the hospital, I’m waiting on the ambulance”.
Throughout the day, she continued to make non-sensical comments but remained
cooperative and responsive. She was noted to be talking to herself and to people that were
not present. Because of these symptoms, staff at rehab transferred to Regions for
evaluation. Continued to hallucinate in ED demonstrated as talking to imaginary people.
Became increasingly agitated. Given IV ativan with decreased both agitation and lucidity.
PMH:
Osteoarthritis
DJD
Multiple fractures 2/2 pedestrian vs vehicle MVA in 1980
HCV
Depression
ADHD
PSH:
s/p anterior cervical discectomy and fusion at C5-6, C6-7 May 2006
s/p right THA and hardware removal on 12/6/06 after failure of THA from 1980
s/p c-section 2/2 sepsis 1987
s/p ex lap 2/2 perforated colon 1975
ROS: unable to obtain secondary to mental status
Meds:
Cymbalta 30mg qday
Wellbutrin 300mg qday
Tramadol 40mg qid
Ambienc 10mg qhs
Adderall 20mg qday
Percocet 102 tabs q4h
Lorazepam 1mg qday
Hydroxyzine 25mg, 1-2 tabs q4h prn
Docusate
Hexavitamin
Calcium/vit D
Warfarin 1mg
Shx:
Living at rehab after recent hip surgery. Smokes 1 cigar/day. Divorced. No employment
secondary to MVA injuries from past.

2. Fhx: Mother had CAD and died of ruptured brain aneurysm/stroke. Father died of MI.
Exam:
VS: T 97.2F, BP 116/84, HR 120, RR 19, O2S 95% RA
Gen: Agitated and lying in bed. Opens eyes to voice intermittently. Tremulous and
diaphoretic.
HEENT: Normocephalic and atraumatic. PERRL. Pt will not cooperate with opening
mouth for OP exam.
Neck: No masses. Trachea midline. Carotids 2+
Lungs: CTA bil, no wheezing or rales
CV: Tachycardic, regular. S1 and S2 normal, no m/r/g
Abd: soft/nt/nd. Bowel sounds normal to hyperactive.
Ext: 1-2+ pitting edema in RLE. LLE without edema. Right hip surgical site is c/d/I with
mild serosanginous drainage. DP and PT pulses 2/2.
Neuro: Not able to follow commands. Opens eyes to pain, voice and touch. Visible
tremors in bil lower extremities. Spontaneous clonus in RLE, inducible clonus with
multiple beats in bil LE, but R>L. Patellar reflexes 3+ bilateral. Biceps reflexes 2-3+ bil.
Bil LE exhibit rigidity bilaterally. Unable to illicit babinski sign due to rigiditiy.
Labs:
• CBC: WBC 10.9 (normal diff), HGb 9.2, Plt 256
• BMP: Na+ 138, K+ 4.0, Chl 107, CO2 25, BUN 12, Crt 0.8, Ca2+ 8.0
• Utox: preliminary presumed pos for amphetamines and THC
• CK 662
EKG: sinus tachycardia
Head Ct: exam was limited by motion. Ventricles and sulci normal. No obvious
intracranial abnormality.
Course:
Agitation/psychosis picture consistent with serotonin syndrome (agitation, rigitidy,
neuro findings).
- started CIWA ativan parameters.
- Attemped cyprohepatdine 12mg PO x1 dose.
- Admitted to MICU
- Started NS at 150ml/hr
- Supportive cares
Libby Zion/Work Hours:

3. 18 y/o female who presented to New York Hospital Cornell Medical Center with fever,
agitation, and “strange jerking motions” of her extremities. Ongoing treatment for
depression. Was admitted and evaluated by an intern and a resident. After discussing the
case with the pts PCP, decided she had a viral illness with “hysterical features” and she
was given mepiridine for pain and sedation. Pts status worsened overnight and crosscover
was notified. However, intern was covering 40-50 other patients some of whom were
very ill. Restraints and haldol were administered. Pt developed fever to 107F, had cardiac
arrest and died.
Family sued for inadequate staffing at teaching hospital. Claimed that long hours and too
many patients were to blame for poor care their daughter received. Father was journalist
at NY Times. Blaimed administration of mepiridine interaction with anti-depressant
caused serotonin syndrome and pt died.
After many trials and cases led to the Bell commission with recommendations for no
more than 24hours of patient care, limit of 80 hours in a work week, and presence of
attending physician in house at all time. New York state first to accept these restrictions
ACGME accepted 80 hour work hour restrictions with no more than 24 hours of active
patient care in 2003. Has caused great amount of discussion and changed through medical
training.
DDx:
Neuroleptic malignant syndrome- longer course, bradyreflexis, muscular rigidity, caused
by dopamine antagonist
Anticholinergic toxicity- muscular tone and reflexes are normal in AC toxicity
Malignant hyperthermia
Intoxication with sympathomimetic agents
Neuro:
Meningitis
Encephalitis
ID:
bacteremia from hip
endocarditis