An Angry Teenager
A 15 years old healthy teenage girl with no relevant medical history, came to the emergency room (ER) with her older sister at 3 am for an acute onset of vomiting after being found in the family bathroom. On their way to the ER, she started behaving unusually and being very aggressive. On arrival to the ER, she was not responding to questions and screaming very loudly for no apparent reason. When asked what was wrong, she only complained of having “too many problems in her life”.
She had no prior symptoms and spent her day without any complaint, her behaviour was normal. There was no history of substance abuse, trauma or infectious symptoms in the past few days. There is no medications at home that she could have taken apart from paracetamol and no alcohol. Her sister insists that this is not her normal behaviour.
On physical exam vital signs are normal except for a slight tachycardia at 100/min during agitation, she is well perfused and hydrated, apyretic. No alcoholic foetor. Cardio-pulmonary exam is normal, as is the digestive system. Neurologic exam shows the behaviour mentioned above, a slight mydriasis on both sides, with a good reactivity to light but is otherwise normal: no sensitive or motor deficit, patellar and radial reflexes are normal, no plantar skin reflex, no dysmetria nor coordination problems. Walk and balance were not tested.
Her aggressiveness increased after examination, she tried to hit and bite the staff at many occasions, security was called and she had to be physically restrained and injected twice with 5mg of Olanzapine intramuscular. After that, a peripheral line was put in place and lab were sent.