OFFICE URGENCIES AND EMERGENCIES
From 25th Annual Primary Care Summer Conference: Office Urgencies and Emergencies, presented by Scripps Clinic
Educational Objectives
| The goal of this program is to improve recognition and management of office urgencies and emergencies. After hearing
and assimilating this program, the clinician will be better able to:
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 | 1. Distinguish between dementia and delirium, and detail some common causes of each.
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| 2. Discuss safety issues when attending to patients with psychosis or agitation.
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| 3. Compare and contrast type 1 diabetes, type 2 diabetes, maturity-onset diabetes of the young, and latent autoimmune
diabetes of adulthood.
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| 4. Identify etiologies of hyperthyroidism and discuss management options.
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| 5. Recognize complications of bariatric surgery.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee
to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the following has been disclosed: Dr. Naimark is on the Speaker’s Bureaus for
AstraZeneca, Eli Lilly, Wyeth, and Forest. Dr. Lee and the planning committee reported nothing to disclose.
Acknowledgments
Drs. Naimark and Lee were recorded at 25th Annual Primary Care Summer Conference: Office Urgencies and Emergencies
, presented by Scripps Clinic, and held August 1-3, 2008, in San Diego, CA. The Audio-Digest Foundation
thanks the speakers and the Scripps Clinic for their cooperation in the production of this program.
Management of Psychiatric Emergencies
David Naimark, MD, Associate Clinical Professor of Psychiatry, University of California, San Diego, School of Medicine
Delirium and Dementia
| Presentation: patients with underlying dementia may present with delirium (important to recognize change in status);
similarities—both involve altered mental state, cognitive impairment, and behavioral problems; both have identifiable
organic etiologies; differences—patients with delirium unable to attend to interview, whereas patients with uncomplicated
dementia can pay attention (but may provide strange answers); level of consciousness fluctuates in
delirious patients, but stable in patients with uncomplicated dementia
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| Etiology of delirium: urinary tract or pulmonary infection (most common causes of delirium in patients with underlying
dementia); others include medications, pain, and alcohol abuse and withdrawal
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| Diagnosis of dementia: memory problems plus ≥1 significant neurologic finding (eg, aphasia, apraxia, agnosia, or
impaired executive functioning); functional impairment prerequisite for diagnosis
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| Reversible dementia: normal pressure hydrocephalus (NPH)—presentation often identical to Alzheimer’s disease
(AD), but accompanied by ataxia and urinary incontinence (triad suggests NPH); cerebral lesion—tumor may cause
symptoms without focal neurologic findings; unusual symptoms (eg, early visual hallucinations) may provide clues to
diagnosis; pseudodementias—medications (eg, anticholinergic agents, pain medications) most common cause; depression
may cause dementia-like symptoms, which generally resolve with treatment (but, these patients often eventually
progress to true dementia); vitamin B12 deficiency—uncommon cause; partially reversible dementias—alcohol
abuse; vascular dementia (control hypertension)
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| Irreversible dementia: AD; frontotemporal dementia (formerly, Pick’s disease; behavior problems manifest before
cognitive problems); Lewy body dementia; Parkinson’s dementia; Jakob-Creutzfeldt disease; syphilis- or HIV-induced
dementia; Lewy body dementia—neuropathologic findings similar to those with AD and Parkinson’s disease;
behavioral problems primary, and may include psychosis, visual hallucinations, and violence; typical antipsychotic
agents generally contraindicated because of risk for neuroleptic malignant syndrome and movement problems; clozapine
(eg, Clozaril) and quetiapine preferred
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| Treating patients with delirium: identify and treat underlying cause; environmental manipulations—keep patient
safe; control environment (eg, keep well-lit); orient patient to time and place
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| Medical therapy: haloperidol (Haldol)—drug of choice for short-term use; long-term use increases risk for tardive
dyskinesia; intramuscular (IM), intravenous (IV), and oral formulations available; droperidol—rarely used because
of adverse effects; olanzapine (Zyprexa)—IM formulation available; associated with less risk for extrapyramidal
effects (good choice for patients with Lewy body dementia); interacts with many medications (eg,
lorazepam [eg, Ativan]); benzodiazepines—often used short-term in combination with haloperidol; “triple cocktail”
of haloperidol, lorazepam, and benztropine (eg, Cogentin) often used for patients with psychotic symptoms
or acute agitation
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| Treating patients with dementia: behavioral problems may require urgent intervention; no treatments approved
by Food and Drug Administration (FDA); nonpharmacologic approaches preferred; antipsychotic agents—all have
black box warning (increased risk for mortality) for use in this population, but effective for managing agitation and
psychosis; mood-stabilizing agents—eg, valproic acid (eg, Depakote) associated with clinical benefit, but blood monitoring
required (may induce chemical hepatitis or thrombocytopenia); other agents—variable success reported with
N-methyl-D-aspartic acid (NMDA) antagonists and cholinesterase inhibitors
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Acute Psychosis and Agitation
| Factors to consider: context; age (affects differential diagnosis); underlying medical problems; psychiatric history;
family history; premorbidity—functional magnetic resonance imaging (FMRI) studies show that brain damage occurs
with each episode of psychosis; early intervention encouraged for patients with premorbid behaviors (eg, social
withdrawal, vague delusional thinking)
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| Symptoms: positive—delusions; hallucinations; thought disorganization; negative—inattention to appearance and
hygiene; social withdrawal; appearance of “being disconnected” during interview
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| Safety issues in office: affective violence—emotionally charged act committed, eg, by psychotic or agitated patient
reacting to environment or to clinician’s actions (eg, patient feels angry or threatened); violence may occur as patient
tries to flee; predatory violence—psychopathologic; committed without conscience or emotion
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| Treatment: associated depression—≥40% of patients who present with psychosis or agitation have underlying depression;
management should include treatment for depression; nonpharmacologic management—environmental
manipulation; crisis intervention; seclusion or restraint only if required for patient safety; pharmacologic
management—typical and atypical antipsychotic agents; benzodiazepines; pain medications if appropriate; electroconvulsive
therapy
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Suicide and Homicide
| Legal liability: physician’s responsibility to assess and document risk, not to predict or prevent behavior
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| Risk factor analysis: intervention focuses on dynamic (changeable) risk factors; static risk factors cannot be
changed; examples of risk factors for suicide—imminence of plan; etiology (eg, mental disorder, personality disorder);
chronicity; presence of anxiety (increases risk for suicide, especially when combined with depression); social
support; availability of weapons; substance use; mental illness; access to lithium (decreases suicidal behavior, but patients
can overdose); examples of risk factors for homicide—drug use most important; estimated 80% of homicides
have link to drug use (typically, stimulants); other risk factors include history of violence, acute psychosis (eg, with
thought insertion or deletion), head injury, younger age, psychopathology, and access to weapons
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Endocrinologic Urgencies: Diagnosis and Management
Michael W. Lee, MD, Attending Physician, Scripps Clinic, Division of Diabetes and Endocrinology, and Center for
Weight Management, San Diego, CA
| Case 1: woman, 24 yr of age, complains of dry mouth, thirst, and leg cramps; symptoms have persisted ≥1 yr; no family
history of diabetes; body mass index (BMI) 20; patient feels healthy otherwise, is well hydrated, and has no focal findings
on examination; laboratory results—blood glucose (BG) 574 mg/dL; bicarbonate 26 mEq/L; some ketones in
urine
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| Differential diagnosis: type 2 diabetes—disease process involves insulin deficiency and insulin resistance; contributing
factors include family history, ethnicity, obesity, and inactivity; diagnosis unlikely due to normal BMI and negative
family history; maturity-onset diabetes of the young (MODY)—early onset; relatively mild hyperglycemia (ie,
impaired fasting glucose, impaired glucose tolerance); autosomal dominant disorder (ie, must have ≥1 parent with
early-onset diabetes); pancreatic β cells function poorly; treated with sulfonylureas to increase insulin secretion; type 1
diabetes—type 1A involves autoimmune destruction of β cells; type 1B has similar phenotype but no evidence of autoimmunity;
latent autoimmune diabetes of adulthood (LADA)—“type 1-½ diabetes”; slowly progressing insulin deficiency,
often manifests in 20s or early 30s; patients often relatively lean and active; management same as for type 1
diabetes
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| Laboratory tests: C-peptide—marker of endogenous production of insulin; hemoglobin A1c (HbA1c )—reflects average
BG over past 3 mo; glutamic acid decarboxylase (GAD) antibodies—evidence of autoimmunity (ie, type 1 diabetes);
case —HbA1c \>14%
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| Treatment: insulin—for initial management, speaker recommends long-acting insulin (eg, glargine, detimer) pens;
simple once-daily treatment sufficiently controls BG until specific management plan in place; initial dose 10 U/day;
patients feel hypoglycemic if BG lowered too quickly; sulfonylureas—appropriate for patients with residual β-cell
function; close follow-up required if used as monotherapy; metformin—decreases glucose output, insulin resistance,
and gluconeogenesis; thiazolidinediones (TZDs)—improve insulin sensitivity and secretion; clinical benefit seen in
≈12 wk; case management—insulin therapy to address insulin deficiency and severe hyperglycemia
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| Follow-up: BG levels improve with low-carbohydrate diet and insulin therapy; C-peptide levels signal decreased endogenous
production of insulin; GAD antibodies absent; additional management—education key; insulin pump therapy
may be option for future; pumps provide continuous basal insulin and bolus doses; subcutaneous glucose sensor
useful for monitoring trends in BG and alerting patient to peaks and troughs; no need for weight loss; continued support
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| Case 2: woman, 32 yr of age, 4 mo postpartum, with 2-mo history of insomnia, tremor, weight loss, and hair loss; examination
reveals mild tachycardia, BMI of 26, exophthalmos, nontender goiter, and evidence of anxiety
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| Differential diagnosis: postpartum thyroiditis—occurs ≤12 mo after delivery; affects ≈10% of postpartum women;
transient hyperthyroidism increases patient’s risk for future episodes of thyroid dysfunction; characterized by mild hyperthyroidism
with no thyroid enlargement, ophthalmopathy, or pretibial myxedema; toxic thyroid nodule—focal
finding; overactive palpable nodule, but no goiter; factitious thyrotoxicosis—may result from thyroid hormone supplementation
(eg, for weight loss); not associated with eye findings or thyroid enlargement; Graves’ disease—most
likely diagnosis; associated findings include hyperthyroidism, goiter, eye findings, and myxedema of lower extremities;
autoimmune process; most common cause of hyperthyroidism
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| Laboratory tests: free thyroxine (T4 ) and triiodothyronine (T3 ) levels substantially elevated
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| Treatment: β blockers (eg, atenolol) best for initial symptom management in thyrotoxic patient; radioactive iodine
therapy or thyroidectomy may be necessary, but not appropriate for short-term management; methimazole—
inhibits synthesis of thyroid hormone; clinical benefit occurs in 3 to 4 wk; low dose (5-10 mg/day) appropriate for
patients with milder symptoms; high dose (20-30 mg/day) necessary for patients with severe symptoms, goiter, or
high levels of thyroid hormones; preferred over propylthiouracil (PTU) because of longer half-life and once-daily
dosing; adverse effects include rash, hepatotoxicity (monitor liver enzymes), and agranulocytosis (rare; if sore
throat or infection with fever develops, patient should discontinue medication and consult physician); methimazole
and PTU safe for nursing mothers, but PTU preferred during pregnancy; atenolol—results in most rapid relief of
symptoms; initiated at 25 to 50 mg/day; may increase dose up to 200 mg/day; preferred over propranolol because of
once-daily dosing and higher β1 -selectivity; case management—atenolol and methimazole
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| Follow-up: at 5-mo, T4 and T3 levels normal; thyrotropin (TSH) level may take several months to normalize
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| Case 3: woman, 49 yr of age, underwent successful gastric bypass surgery 1 yr previously; weight and BMI decreased
substantially; recent onset of postprandial epigastric pain
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| Gastric bypass surgery: stomach resected (1-oz gastric pouch remains) and much of intestine bypassed; procedure
results in restricted food intake and dumping syndrome (adverse reaction to ingesting simple sugars and carbohydrates);
vitamin D—often deficient after gastric bypass; deficiency may result in secondary hyperparathyroidism
(risk increases with time), which increases risk for bone loss; treatment requires prescription ergocalciferol (vitamin
D2 ; high potency, given once-weekly); low risk for hypercalcemia because of decreased absorption of vitamin
D with gastric bypass; patients require long-term follow-up for osteoporosis; nonsteroidal anti-inflammatory drugs
(NSAIDs)—contraindicated after gastric bypass; increase risk for gastrointestinal (GI) bleeding; acetaminophen,
tramadol, and opiates acceptable alternatives for pain management; vitamin B12 —deficiency commonly occurs after
gastric bypass; sublingual B12 supplement, once or twice weekly, typically sufficient (injections sometimes necessary);
cyclooxygenase (COX)-2 inhibitors—also may cause GI bleeding in these patients
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| Return to case: patient denies use of NSAIDs, describes pain as intermittent and crampy, and reports tolerance of liquids
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| Differential diagnosis: anastomotic stricture—occurs in 10% to 15% of gastric bypass patients; develops at anastomosis
of gastric pouch and Roux limb, within 3 mo after surgery; restricts ability to swallow food or fluids (even saliva);
requires endoscopic dilation; gallstones—common among obese patients and those losing weight;
cholecystectomy commonly performed before or at time of gastric bypass if patient symptomatic; asymptomatic patients
do not benefit from removal; patients routinely given ursodiol (300 mg bid) for 6 mo after surgery; marginal
ulcer—occurs at anastomosis of gastric pouch and Roux limb; symptoms include abdominal pain, bleeding, anemia,
and vomiting; patients using NSAIDs or tobacco must discontinue use; acid suppression therapy initiated; internal
hernia—uncommon but serious complication; increased risk after laparoscopic approach, due to decreased formation
of adhesions; loss of significant amount of weight may create space in abdominal cavity, allowing intestines to pivot
and become obstructed; results in recurrent, colicky abdominal pain; generally occurs \>12 mo after surgery
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| Follow-up: referral to bariatric surgeon; exploratory laparoscopy revealed internal hernia; repair successful
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| Other issues: gastric banding associated with fewer complications than gastric bypass; if band too tight or if erosion or
slippage occurs, similar obstructive symptoms result; requires evaluation and surgery
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| Questions and answers: initiating insulin therapy—consider BG level and overall health and appearance; patients
with severe hyperglycemia, acidosis, or ketones in urine generally require insulin; approaches to managing
hyperthyroidism—dose methimazole based on severity of disease; monitor thyroid hormone levels and liver function
every 8 wk; long-term therapy acceptable, if tolerated; remission occurs in some patients; consider alternatives before
recommending thyroid radioactive iodine therapy
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Suggested Reading
Brent GA: Clinical practice. Graves’ disease. N Engl J Med 358:2594, 2008; Clements RH et al: Hyperparathyroidism
and vitamin D deficiency after laparoscopic gastric bypass. Am Surg 74:469, 2008; Friedrich N et al: Association between
parity and autoimmune thyroiditis in a general female population. Autoimmunity 41:174, 2008; Goldberger ZD et al: Clinical
problem-solving. Variations on a theme. N Engl J Med 359:1502, 2008; Jorm AF et al: A comparison of clinician, youth,
and parent beliefs about helpfulness of interventions for early psychosis. Psychiatr Serv 59:1115, 2008; Kuehn BM: FDA:
Antipsychotics risky for elderly. JAMA 300:379, 2008; Nabhan F et al: Latent autoimmune diabetes of adulthood. Unique
features that distinguish it from types 1 and 2. Postgrad Med 117:7, 2005; Nock MK et al: Suicide and suicidal behavior. Epidemiol
Rev Jul 24, 2008 [Epub ahead of print]; Pae CU et al: Delirium: Underrecognized and undertreated. Curr Treat Options
Neurol 10:386, 2008; Schneider B et al: How do personality disorders modify suicide risk? J Personal Disord
22:233, 2008; Tice JA et al: Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures.
Am J Med 121:885, 2008; Wilber ST et al: The six-item screener to detect cognitive impairment in older emergency
department patients. Acad Emerg Med 15:613, 2008.
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