Climate, heat and eco-distress in a community service (MEQ)

(a) The woman on lithium — 8 marks

Lead with the reframe: this is lithium toxicity until a level says otherwise. Coarse tremor, ataxia, vomiting and confusion in a hot week with reduced intake is a pharmacological emergency wearing the costume of a mood relapse.^[8][9]

Immediate actions, in order:^[8][9][7]

1. Observations including core temperature, hydration status, conscious level and neurological examination for tremor, ataxia and myoclonus.^[7]
2. Lithium level, urea and electrolytes, creatinine, plus glucose and calcium as clinically indicated; withhold lithium pending the result.^[8][9]
3. Rehydrate and cool; escalate to a medical bed rather than a psychiatric bed if toxicity is confirmed or the patient is confused.^[7][9]
4. Review the full drug chart for the multipliers: diuretics, ACE inhibitors, NSAIDs, anticholinergics and antipsychotics.^[8][9]
5. Exclude the mimics — heat stroke, infection, neuroleptic malignant syndrome and serotonin toxicity — before attributing anything to mood.^[10]

The mechanism you state out loud: sweating, reduced intake and gastrointestinal losses contract volume, the sodium-avid kidney reabsorbs lithium, and the level rises on an unchanged dose.^[8][9]