History of Present Illness
54-year-old female brought to the ED by her 18-year-old son, David. Patient was found on the bathroom floor and has had intractable vomiting since last night. Denies prior stomach problems, new medications, or recent travel. Husband passed away a few years ago from COVID-19.
Emergency Department Course
Initial Assessment
Patient arrival with severe continuous emesis.
Initial Assessment
Patient arrival with severe continuous emesis.
Medical Decision Making
Initial priority is to halt the vomiting and assess for potential infectious, obstructive, or toxicologic causes while checking basic labs to assess volume and electrolyte status.
Diagnostics & Findings
- Basic Metabolic Panel (BMP)
Findings:
- No prior abdominal history
- No recent travel
Interventions
- Ondansetron (Zofran) x 4 doses
⮑ Outcome & Reassessment
Vomiting persists despite multiple doses of antiemetics.
Lab Review & Treatment
Lab results return showing electrolyte derangement.
Lab Review & Treatment
Lab results return showing electrolyte derangement.
Medical Decision Making
Hypokalemia is a direct result of profound gastric acid and fluid loss, leading to renal potassium wasting (metabolic alkalosis). Must aggressively replete potassium to prevent cardiac arrhythmias.
Diagnostics & Findings
- Lab Review
Findings:
- Potassium 3.1 mEq/L
Interventions
- 10 mEq Potassium Chloride IV
- 20 mEq Potassium Chloride PO
⮑ Outcome & Reassessment
Potassium repletion initiated; patient continues to appear distressed.
Behavioral Intervention & Discovery
Dr. McKay reports a 'weird vibe' regarding the mother-son dynamic, suspecting elder abuse or poisoning.
Behavioral Intervention & Discovery
Dr. McKay reports a 'weird vibe' regarding the mother-son dynamic, suspecting elder abuse or poisoning.
Medical Decision Making
When abuse, coercion, or a hidden agenda is suspected, the standard of care is to separate the patient from the accompanying family member safely. Suggesting a sensitive exam (pelvic exam) provides an unchallengeable medical excuse to clear the room.
Diagnostics & Findings
Findings:
- Patient confesses to intentional self-poisoning with Ipecac syrup.
- Patient reveals she induced vomiting to force her son into the ED because she found a 'death list'.
Interventions
- Falsely ordered a pelvic exam to dismiss the son
⮑ Outcome & Reassessment
Patient is relieved to speak privately but is highly anxious about her son's psychiatric state.
Diagnoses & Disposition
Evolving Diagnoses
- [Initial Assessment]Intractable vomiting, unspecified etiology
- [Lab Review & Treatment]Hypokalemia secondary to GI losses
- [Behavioral Intervention & Discovery]Ipecac toxicity (Self-induced)
Current Disposition
Patient is medically stable in the ED, receiving IV fluids and potassium. Psychiatric/law enforcement emergency escalated as the homicidal son eloped from the hospital.
Casebook Analysis
Episode Context
Theresa intentionally poisoned herself with Ipecac to circumvent the police and force her 18-year-old son, David, into a healthcare setting. She discovered a hit-list of girls he planned to kill, but as a grieving mother, she wanted him to receive psychiatric help rather than immediate police intervention.
Attending's Review
Medical Accuracy
The use of a 'fake' intimate exam (like a pelvic exam) to clear family members from the room is a highly accurate and frequently utilized tactic in Emergency Medicine to screen for domestic violence, abuse, or hidden social crises. The medical treatment of hypokalemia with both IV and PO potassium is also protocol-accurate. Ipecac syrup is largely obsolete and no longer recommended for home use, but it's plausible an older household might still have a bottle.
Clinical Pearls
When evaluating intractable vomiting, always check an ECG and a BMP. Hypokalemia from severe emesis is caused by renal potassium wasting as the kidneys attempt to compensate for metabolic alkalosis.
If you suspect coercion, abuse, or a hidden agenda, creatively separate the patient from their companions. An offer for a 'sensitive physical exam' or taking the patient to radiology alone are standard maneuvers.
A specific, credible threat of violence against named individuals triggers the 'Duty to Warn' (Tarasoff rule). Law enforcement and hospital security must be involved immediately to prevent the subject from eloping.
