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CASE:Dr. Andrew Cruz (Psychiatry): A 27-year-old woman was evaluated at this hospital because of a suicide attempt.
Approximately 3 months before admission, the patient became homeless and was staying intermittently with friends. Two months before admission, she began to ingest clonazepam daily, and 3 weeks before admission, she began to use intranasal heroin daily. She had depression and anxiety, and 2 days before admission, she expressed that she felt “tired of living this life” and wanted “to end it all.”
On the evening of presentation, the patient reportedly smashed her cell phone on the ground and ate the glass shards as a suicide attempt. Nausea and diffuse abdominal discomfort developed, and she reportedly had an episode vomiting, with the vomit containing 2 teaspoons (10 ml) of blood. Three hours after the ingestion, she presented to the emergency department of this hospital with throat, chest, and abdominal pain. She reported that she had “regret” about the ingestion and wanted “help” with her substance use and suicidality.
The patient reported past sexual trauma but did not provide details; she did not report any previous suicide attempts, homicidal ideation, or hallucinations. A limited review of systems was notable for anorexia, diaphoresis, diarrhea, impaired sleep, fatigue, mood lability, nightmares, and flashbacks. Her psychiatric history included polysubstance use disorder (with the use of intravenous heroin, fentanyl, benzodiazepines, and cocaine), cutting behavior during adolescence, and anxiety and depression. She had never undergone psychiatric treatment or hospitalization. Her medical history included hepatitis C virus infection, obesity, genital herpes simplex virus infection, and a low-grade squamous intraepithelial lesion of the cervix; in addition, a motor vehicle collision had led to open reduction and internal fixation involving the left arm. She took no medications and had no known adverse reactions to medications. She worked in a local store and had a small child. She had smoked one and a half packs of cigarettes daily for the past 10 years and was a current smoker. She drank 1 pint of vodka daily and reported no history of withdrawals or blackouts. Multiple relatives, including both of her parents, had a history of substance use disorder.
On examination, the temperature was 36.8°C, the pulse 70 beats per minute, and the oxygen saturation 96% while the patient was breathing ambient air. She appeared disheveled, tearful, and anxious. Abdominal examination revealed mild tenderness on the right side on palpation. On examination by a psychiatrist, she had limited eye contact and mumbling speech, along with poor concentration, depressed mood with a congruent affect, and poor insight and judgment. The complete blood count and levels of electrolytes, urea nitrogen, creatinine, lactate, bilirubin, alkaline phosphatase, and albumin were normal; the aspartate aminotransferase level was 162 U per liter (reference range, 9 to 32), and the alanine aminotransferase level was 52 U per liter (reference range, 7 to 33). Ethanol was not detected in the blood, and human chorionic gonadotropin was not detected in the urine. A urine toxicology screen was positive for opioids and cocaine metabolites. The findings on an electrocardiogram were normal and unchanged from a tracing obtained 10 years earlier.
Dr. Efren J. Flores: The results of radiography of the neck, chest, and abdomen were normal, without a visible radiopaque foreign body. Computed tomography (CT) of the abdomen and pelvis, performed after the administration of intravenous contrast material (Figure 1), revealed gallbladder wall thickening and trace perihepatic fluid. These findings can be seen in patients with acute hepatitis. There was no evidence of pneumoperitoneum or of a radiopaque foreign body.
Dr. Cruz: Intravenous normal saline, morphine sulfate, and piperacillin–tazobactam were administered. The patient was evaluated by the surgery and psychiatry services. Because of concern about the patient’s risk of self-harm, an order that authorized temporary involuntary hospitalization was implemented.
The next evening, the patient reported that while she was trying to get out of a stretcher, she “heard a pop” in her right elbow, which was accompanied by immediate pain without any numbness or tingling. On examination by an orthopedic surgeon, the olecranon process appeared to protrude posteriorly and medially without ecchymosis. The patient was not able to move the arm at the elbow, although range of motion was intact at the shoulder and wrist.
Dr. Flores: A lateral image of the right elbow (Figure 2A) showed posterior dislocation of the elbow with impaction of the olecranon process of the ulna into the distal humerus outside the olecranon fossa. An anteroposterior image of the right elbow (Figure 2B) confirmed dislocation of the elbow with malalignment of the ulnotrochlear and radiocapitellar joints.
Dr. Cruz: After the administration of acetaminophen, ibuprofen, oxycodone, and intravenous morphine, the elbow was manually reduced and a splint was applied. Additional radiographic images were obtained.
Dr. Flores: Lateral and anteroposterior images of the right elbow obtained after closed reduction and splinting (Figure 2C and 2D) showed normal alignment of the ulnotrochlear and radiocapitellar joints.
Dr. Cruz: During the next 18 hours, the patient remained under observation, with a plan for transfer to an inpatient psychiatric hospital for ongoing care. One hour before transfer, the patient went to the bathroom without her observer and then reported that she could not move her right arm.
Dr. Flores: A lateral image of the right elbow showed that the splint was in place and showed posterior dislocation of the elbow with impaction of the olecranon process of the ulna into the distal humerus outside the olecranon fossa. An anteroposterior image of the right elbow confirmed dislocation of the elbow with predominant involvement of the radiocapitellar joint. There was irregularity of the radial head and lateral humeral epicondyle that was consistent with a nondisplaced fracture.
Dr. Cruz: Intravenous morphine was administered. The elbow was again reduced, and a circumferential fiberglass cast was placed.
Dr. Flores: A lateral image of the right elbow obtained after the second closed reduction and casting showed normal alignment and the presence of a cast.
Dr. Cruz: The next afternoon, after the plan for transfer to a psychiatric hospital was shared with the patient, she was found in the bathroom without her observer, where she was banging her left arm against the wall. She reported pain, and oral oxycodone and intramuscular hydromorphone were administered.
Dr. Flores: A lateral image of the left elbow obtained hours after the second reduction and casting of the right elbow (Figure 2E) showed posterior dislocation of the left elbow and a fragment from a displaced fracture of the trochlea. There were two screws in the lateral humeral epicondyle from previous open reduction and internal fixation.
Dr. Cruz: Intraarticular nerve block was performed. The left elbow was reduced, and a long-arm circumferential fiberglass cast was placed.
Additional management decisions were made.
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