Transcript Int J Med Toxicol 2003

Bryan S Judge, MD
IUSOM Medical Toxicology Fellowship
ACMT CPC Competition
September 5, 2003
Case Presentation
• 25 year-old male
• Chief complaint: Dyspnea
• Diagnosed with Pneumocystis
carinii pneumonia at another ED
• Patient transferred to a tertiary
referral hospital
Past Medical History
• Illicit drug abuse with several prior
admissions to drug rehabilitation
centers
• Negative HIV antibody test within
the last year
• Denies regular use of any
prescription or OTC medications
• Has no known drug allergies
Social History
• History of intravenous cocaine,
heroin and methamphetamine
abuse
• Unemployed, lives with girlfriend
• Smokes 1 pack of cigarettes/day
• Denies use of ethanol
• Occasional marijuana use
Case Presentation
• Patient remained dyspneic upon
arrival to the tertiary referral
hospital
• Patient denied use of cocaine,
heroin, or methamphetamine for
several days
Case Presentation
• He admitted to taking 2
carisoprodol tablets within the last
24 hours
• Patient denied any cough, fever,
chills, chest pain, recent weight
loss, or sharing of needles
Case Presentation
• “Yeah, the shit that killed [rock star].
I knew it had to be a good trip if it
killed [rock star]!”
Pertinent Physical Exam
Findings
• Vitals: T- 98.3°F
RR- 30/min
P- 105/min BP- 112/72 mmHg
O2 Sat- 82% on room air
O2 Sat- 91% on 100% NRB
• General: Well nourished and in mild
respiratory distress
Pertinent Physical Exam
Findings
• Heart: Tachycardic without murmur or
rub
• Lungs: Diffuse rales bilaterally
• Extremities: Track marks in the left
antecubital fossa and multiple tattoos on
chest and arms
• Remainder of exam is unremarkable
Complete Blood Count
15.8
15.9
240
45.0
60% Neutrophils
26% Lymphocytes
6% Monocytes
Chemistry Panel
138
105
12
141
4.6
23
0.7
Anion gap = 10
Other Studies
• Calcium: 8.6 mg/dL
• Arterial Blood Gas on Room Air:
– pH:
– pCO2:
– pO2:
– HCO3-:
7.40
34 mmHg
46 mmHg
23 mEq/L
Other Studies
• ECG:
– Sinus tachycardia
– QRS – 88 msec
– QTc – 390 msec
– No ectopy and no ischemic changes
• Salicylate, APAP and Ethanol Levels:
– All are nondetectable
Other Studies
• Urine Drug Screen:
– Amphetamines – Negative
– Cocaine – Negative
– THC – Positive
– Benzodiazepines – Negative
– Barbiturates – Negative
– Tricyclic Antidepressants – Negative
– Opiates – Negative
Making The Diagnosis
• Further history provided by the
patient helped to elicit the etiology
behind his clinical condition