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The patient was a 60 year-old woman who was brought to the emergency room (at 17:00 hrs) after she was found on the floor of her home by her daughter.

Personal history:
Because of bipolar disorder the patient has been treated by a psychiatrist for 10 years. Her affective disorder was well controlled with 300 mg of lithium carbonate (Li) twice daily. For routine follow-up she was seen by her psychiatrist four weeks ago. No problems were reported. Two weeks before her admission, the patient was seen by her primary care physician who newly diagnosed hypertension and prescribed hydrochlorothiazide (125 mg per day). Present patient´s state:

A general physical examination found:
severe tremor, dysarthria, ataxia, neuromuscular irritability, muscle rigidity, vertical nystagmus, apathy, impaired consciousness (disorientation to time and place).

Examinations:
Plasma laboratory studies revealed: mildly elevated plasma sodium and chloride measures to 155 mEq/L and 120 mEq/L, respectively. She had a slight metabolic acidosis.The remainder of routine laboratory studies, thyroid functions and urine toxicology screen were negative. ECG showed no signs of Li toxicity (bradycardia,T-wave depression), a chest radiogram was negative.