A 28-Year-Old Man with a History of Bipolar I Disorder

question 6

Multiple Choice

A 28-year-old man with a history of bipolar I disorder is brought to the emergency department after being pulled over by police for driving erratically.  The police report indicates that the patient appeared alcohol-intoxicated and refused to cooperate with questions, stating, "I have the skills of a race car driver and a need for speed."  He has been on lithium for years and says he has been adherent.  The patient has a history of bilateral knee injuries sustained in an accident when he jumped from a high ledge.  He has no other medical history.  The emergency physician contacts the outpatient psychiatrist, who reports that the patient has been treated with lithium for the past 3 years.  He had a therapeutic lithium level and appeared stable at his last visit 2 weeks ago.  The patient is re-interviewed when he is sober.  He felt upset after his girlfriend left him and was turned down for a job, and so decided to "get drunk."  He is apologetic for driving recklessly and says he intends to follow up with his outpatient psychiatrist.  Although the patient admits to a history of crack cocaine use, he currently uses no illicit substances other than marijuana on weekends.  Temperature is 37.2 C (99 F) , blood pressure is 140/80 mm Hg, and pulse is 88/min.  Physical examination is normal.  The patient is alert, and his speech is nonpressured.  Urine toxicology screen is negative for illicit substances.
Which of the following is the most appropriate next step in management?

• A)Check lithium level and adjust dose if subtherapeutic
• B)Discharge patient after arranging a follow-up appointment with his outpatient psychiatrist
• C)Discharge patient with a referral for substance abuse counseling
• D)Perform a suicide risk assessment
• E)Treat patient prophylactically for alcohol withdrawal

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Definitions:

Sex Hormones

Chemical substances produced by the body that regulate sexual development, behavior, and reproductive functions.

Hypothalamus

A region of the brain responsible for producing hormones that regulate vital bodily functions, including hunger, thirst, sleep, and various emotional responses.

Feedback Loop

A system in which glands regulate each other’s functioning through a series of hormonal messages.

Pituitary Gland

The pituitary gland is a small, pea-sized gland located at the base of the brain, important for controlling growth, metabolism, and the function of other glands in the endocrine system.