Violent Behavior and Hallucination in a 32-Year-Old Patient

A 32-year-old white male was brought to the emergency department by police after a sudden, dangerous outburst. He had allegedly assaulted his girlfriend and attempted to run her over with his car. Subsequently, the patient reportedly stole and/or damaged numerous other motor vehicles. Several security and law enforcement officers were required to subdue the patient and bring an end to his hallucination-driven rampage, which lasted about 2 hours. The patient's medical history included chronic back pain, hypertension, and a long history of substance abuse, including alcohol, tobacco, and marijuana. A physical examination revealed the following: blood pressure, 132/88 mmHg; heart rate, 135 beats/min; respiratory rate, 18/min; body temperature, 98.7 °F; oxygen saturation, 98% on room air. He was markedly anxious, distressed, and sweating profusely. His pupils were normal in size and reactive to light. The patient had mild abrasions on his hands, arms, and shoulders, but he had no severe injuries. He progressively became more agitated in the emergency department and required 10 mg ziprasidone intramuscularly and 2 mg lorazepam intravenously for sedation. Intoxication with psychoactive substances was suspected; however, the results of routine screening tests of serum and urine samples were negative for alcohols, amphetamines, cocaine, and opioids. For cases in which drug abuse is high on the differential but the results of routine drug screening are negative, physicians and laboratorians should consider the analytical sensitivity and specificity of the assays they have used to perform the screen. For example, although a patient may have overdosed on oxycodone, does the laboratory's general opiate immunoassay detect this synthetic opioid? Local availability and use of illicit drugs, including designer drugs, also need consideration. Phencyclidine can induce a clinical presentation similar to the one described above, but it is rarely used in our region and is therefore not included in the routine …