Post on 12-Jan-2016
Bryan S Judge, MDIUSOM Medical Toxicology
FellowshipACMT CPC Competition
September 5, 2003
Bryan S Judge, MDIUSOM Medical Toxicology
FellowshipACMT CPC Competition
September 5, 2003
Case PresentationCase Presentation
• 25 year-old male• Chief complaint: Dyspnea• Diagnosed with Pneumocystis
carinii pneumonia at another ED
• Patient transferred to a tertiary referral hospital
• 25 year-old male• Chief complaint: Dyspnea• Diagnosed with Pneumocystis
carinii pneumonia at another ED
• Patient transferred to a tertiary referral hospital
Past Medical HistoryPast 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
• 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 HistorySocial 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
• 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 PresentationCase Presentation
• Patient remained dyspneic upon arrival to the tertiary referral hospital
• Patient denied use of cocaine, heroin, or methamphetamine for several days
• Patient remained dyspneic upon arrival to the tertiary referral hospital
• Patient denied use of cocaine, heroin, or methamphetamine for several days
Case PresentationCase 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
• 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 PresentationCase Presentation
• “Yeah, the shit that killed [rock star]. I knew it had to be a good trip if it killed [rock star]!”
• “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
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
• 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
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
• 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 CountComplete Blood Count
15.815.815.815.8
45.045.045.045.0
242400
242400
15.915.915.915.9
60% Neutrophils
26% Lymphocytes
6% Monocytes
60% Neutrophils
26% Lymphocytes
6% Monocytes
Chemistry PanelChemistry Panel
138138138138 105105105105
4.64.64.64.6 23232323 0.70.70.70.7
12121212141141141141
Anion gap = 10Anion gap = 10
Other StudiesOther Studies
• Calcium: 8.6 mg/dL• Arterial Blood Gas on Room
Air:– pH: 7.40
– pCO2: 34 mmHg
– pO2: 46 mmHg
– HCO3-: 23 mEq/L
• Calcium: 8.6 mg/dL• Arterial Blood Gas on Room
Air:– pH: 7.40
– pCO2: 34 mmHg
– pO2: 46 mmHg
– HCO3-: 23 mEq/L
Other StudiesOther Studies
• ECG:– Sinus tachycardia– QRS – 88 msec– QTc – 390 msec– No ectopy and no ischemic changes
• Salicylate, APAP and Ethanol Levels:– All are nondetectable
• ECG:– Sinus tachycardia– QRS – 88 msec– QTc – 390 msec– No ectopy and no ischemic changes
• Salicylate, APAP and Ethanol Levels:– All are nondetectable
Other StudiesOther Studies
• Urine Drug Screen:– Amphetamines – Negative– Cocaine – Negative– THC – Positive– Benzodiazepines – Negative– Barbiturates – Negative– Tricyclic Antidepressants –
Negative– Opiates – Negative
• Urine Drug Screen:– Amphetamines – Negative– Cocaine – Negative– THC – Positive– Benzodiazepines – Negative– Barbiturates – Negative– Tricyclic Antidepressants –
Negative– Opiates – Negative
Making The DiagnosisMaking The Diagnosis
• Further history provided by the patient helped to elicit the etiology behind his clinical condition
• Further history provided by the patient helped to elicit the etiology behind his clinical condition