The ‘SILENT Alarm’: When history taking reveals a potentially fatal toxicity

Introduction: The combination of acute/sub-acute neurological and metabolic derangements should always raise the suspicion of toxicity, either endogenous or exogenous. The adverse effects of psychiatric medications are especially difficult to determine since the psychiatric background of patients is often inaccessible. Clinical Presentation: A 66-year-old man presented to the emergency department with dysarthria and uncontrolled tremor, rapidly deteriorating into a complex of severe neurological and metabolic derangements. Only after repeated attempts to take a thorough history was lithium toxicity identified. Conclusion: Thorough, comprehensive history taking, including chronic medications and their substitutes, is essential and lifesaving when potentially lethal medications are involved. LEARNING POINTS • Meticulous direct and collateral history taking is essential for correct diagnosis and to reveal psychiatric diagnoses and medications not reported by patients and caregivers. • As drug interactions can cause potentially fatal side effects, it is of the utmost importance to gain access to the patient's full medication list. • It is important to educate patients about the potential toxicity of their prescribed medications and to encourage them to seek medical attention when serious manifestations of toxicity are present.