Sudden Behavioural Changes & Mood Disorders

ED senior remarked that he is escorted by police for disrupting the peace by damaging public property. Not much is known about the patient except his forensic records revealed that he underwent:-

- community service for juvenile theft in his mid teens

- troubled past with polysubstance use

- convicted of assault and imprisoned from 2007-2013

- voluntarily admitted under Pusat Al-Islah from 2013-2015

No records exist from 2015 onwards.

!

However police interviewed some eyewitnesses familiar with him who often spotted him working in the nasi katok stall at Serusop for the past 7 years. He would sleep below the stairs on the shoplots in the night. Sometimes he would be spotted screaming and kicking door entrances. His employer could not be reached at present.

Once arriving at trolley area, ED senior exercised caution as he sedated pt with IM midazolam 5mg 40 min ago due to aggressive behaviour.

Upon entering Room 2, you find 2 police officers and the patient on the stretcher with one arm and foot handcuffed to the frame. He is semi-conscious, barely opening eyes to voice and mumbling. You ask him for his name but he is neither oriented in time, place or person.

You attempt to get some collateral from police officers however they know little and are only present until pt is admitted to the ward. As you proceed to perform physical exam on the pt, he starts to exhibit signs of aggression by unshackling himself from the handcuffs while grunting.

TAMING THE BEAST

After successfully persuading the patient to take oral sedation, you perform a quick neurological exam before he dozes off. Able to follow most instructions and neurologically intact except for reduced sensation & proprioception all limbs. You noticed bruises and superficial ulceration on his MCP joints as well as an infected Rt toe with poorly healed foot ulcers. Apart from reduced JVP and dry mucous membranes, rest of examination is unremarkable and you note your findings.

Post-take

During PTWR, you present your case to the medical consultant oncall and treating the patient as hyperglycemia not in crisis on BG of poorly-controlled T2DM, AKI 2” dehydration and infected diabetic foot ulcers. Your consultant agrees with your assessment and decides for admission under AMU with Psych & Ortho input. In addition, your consultant asked the following:-

Which of the following is the least appropriate intervention for this scenario?

A: Address cognitive impairment and/or disorientation

B: Address potential sources of infection

C: Address disturbed behaviour with sedation

D: Address pain

E: Promote good sleep patterns

ESCALATING TENSIONS

You move patient to one of the AMU rooms and initiate delirium management protocol.

You identify the source of the infection to come from the Rt foot however there appear to be multiple small abscesses below the knee.

You captured an image and WhatsApped to your SMO who recommended escalating Abx to IV meropenem, repeat set of investigations including FBC, CRP, UEC, LFT, blood CS & CXR.

Patient’s condition deteriorated slightly on the next 30-minute review and following discussion with your senior you are asked to refer to ICU for supportive therapy and notify the ID team.

Within an hour later, lab phoned the nursing staff informing that the pus swab grew Burkholderia pseudomanii.