The Case


Bizarre, disorganized behavior


23 yo M with unknown pmh sent from Rikers c/f psychosis and med/psych evaluation in light of “bizarre, disorganized behavior.”  Per records sent from Rikers, patient has history of cannabis and alcohol abuse and tested positive for benzos at Rikers.  No known prior psychiatric history.  Initially sent to CPEP but was brought to ED after witnessed seizure-like activity, though patient responded to sternal rub and did not appear to have have postictal state.

Patient was reportedly yelling and talking to himself in his cell, stating people are “plotting to kill me” and appeared scared and paranoid.  He answers some questions but continues to yell “turn the music off” and intermittently fights against restraints, yells, kicks, and screams at cops begging them to remove handcuffs. Reports benzodiazepine use one month ago. Denies any additional past medical history.

On ROS states his throat hurts a little, unable to state when this started.  Denies any HA, n/v, pain, sob, cp, abd pain, f/c, neck stiffness.


PMH: denies
PSH: denies
Meds: denies
Social: Rikers Island x4 days. Reports occasional etoh, cannabis, and benzodiazepine use

Physical Exam

BP 109/61, HR 96,  RR 24, O2 99% (RA) Temp 99, BG 146

GEN: Becoming increasingly more agitated initially distractable now screaming, kicking. Non-toxic
HEENT: NC/AT, neck supple. Normal ROM. No tonsillar exudate. Uvula midline.
CV: RRR, S1/S2, no mm. Strong and equal peripheral pulses
Pulm: Tachypneic but CTAB, unlabored, no wheezing
Abd: Soft, thin, nt/nd
Ext: No LE edema, wwp
Neuro: Moving all extremities spontaneously. No focal neuro deficit. CN intact. A&O person, month, year, president. Not name of hospital or date. Pt also cannot remember that he is arrested.
Psych: Responding to external stimuli, disorganized thought process.


VBG: pH 7.32, pCO2 43, pO2 111, Lact 0.6
CBC: 18.3>14.9/44.8 BMP: 138/4.3 104/22 17/0.9 Gluc: 121 Ca: 10.0
LFT: AST 54, ALT 39, AlkP 67, Tbil 1.7, Dbil 0.7, Prot 8 , Alb 4.9
EtOH: <10
TSH: 2.5
No utox or UA obtained

Cell Count: RBC 0, WBC 1, Lymph 2%, Mono 1%
Gluc: 87 (range 40-80)
Protein: 21.4
Gram Stain: Rare WBC, no organisms



  1. What diagnosis can you make from these images alone?

  2. What do you suspect was the underlying cause of this diagnosis?

  3. What imaging do you want next?

  4. What are your next steps in management?