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